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Its Symptoms, SsQUELiE, and TREATMENi^r- ' ' ^^\ 

¥ 4^ % 


LLiD. (Ed.), S\E.C.P.E., E.R.S.E. 


FOK Sick Children, and to the Eoyal Public Dispensary, 

EDmBiTRGu ; Consulting Physician to Leitii Hospital, 

formerly Physician to Chalmers Hospital, 

Edinburgh, etc. ; Member of the TJni- 

vERSiTY Court of St. Andrews 

Nascentes morimur, finisque ah origine pendet 

— Manilius, Astronomicon, iv. 16 



All rights reserved 

COPTRIGB^, 1894, 



NotlnonS ^ItfBS : 

J. S. Cushing & Co. — Berwick & Smith. 

Boston, Mass., U.S.A. 


Disease often deranges the mechanism of the 
cardiac valves, and thus places an actual or con- 
structive obstacle in the way of the onward flow 
of the blood. To maintain the circulation under 
these conditions the myocardium must hypertro- 
phy — the heart necessarily enlarges. This we all 
know. But few realize that the loss of elasticity, 
and other changes which the arterial system under- 
goes, during our progress from youth to age, also 
cause a hindrance to the onward flow of the blood 
which has to be compensated in a similar manner. 
In late life, and without any history of previous 
disease, the heart is often found to be enlarged, 
and this enlargement is under these circumstances 
said to be idiopathic. But enlargements of the 
heart form no exceptions to the universal law 
that there is no effect without an antecedent cause. 

Owing to the changes in the vascular system 


just referred to, no heart reaches advanced age 
without some degree of enlargement. This trifling 
enlargement is of slow growth, gives rise to no 
symptoms, and is only found when looked for. 
But when after middle life distressing symptoms 
attract attention to the heart, in by far the larger 
proportion of cases there is discoverable no history 
of any antecedent myocarditis or other disease, 
but the symptoms are entirely due to disturbance 
of the nutrition or of the innervation of the 
myocardium interfering with and modifying the 
normal senile enlargement of the heart. 

By far the most widespread and most interest- 
ing varieties of cardiac disease are to be found 
in this connection, while the comfort and lon- 
gevity of many depend upon a clear understand- 
ing of the various causes which contribute to 
such modifications of the Senile Heart, and 
an appropriate treatment of the many distressing 
symptoms so often associated with it. 

17 Walker Street, Edinburgh, 
February, 1894. 


Chapteb Page 


I. Inteoductokt 

II. How THE Heart is affected by Age 

III. Symptoms and Signs op the Senile Heart 

IV. Palpitation, Tkemor Cohdis, Tachycardia 
V. Bradycardia, and Delirium Cordis . 

VI. Angina Pectoris 

VII. Concomitants and Sequelje op the Senile 
Heart. Gout ...... 

VIII. Concomitants and Sequels op the Senile 
Heart. Glycosuria, Gouty Kidneys . 

IX. The Therapeutics op the Senile Heart 

X. The Therapeutics op the Senile Heart 
Exercise and Diet .... 

XL The Therapeutics op the Senile Heart 
Drugs likely to be Useful, and how to 
USE them ....... 







XII. The Prognosis op Special Symptoms. Reca- 
pitulation OP Treatment with Special 
Reference to Symptoms .... 286 


PieuEE Paoe 

1. Innertation of Heart 38 

2. Sphtgmogram of Peeble and Irregular Pdise . 46 

3. ■) Sphtgmogram of Irregular Pulses in Dilated 

4. > Hearts 49 

5. Sphtgmogram of Tachtcakdiac Pulse . . 78 

6. Sphtgmogram of Hemiststolic Bradtoardia . 106 

7. Sphtgmogram of True Bradtcardia . . . 107 

8. KiDGED GouTT Nail 177 

9. Furrowed Nail 177 

10. Heberden's Knobs 179 

11. Hatgarth's Nodosities 181 





The late Sir Robert Christison, in his first 
report on the emerged risks of the Standard 

Assurance Company, stated that the „ ,^ 

^ ■' Death rarely 

statistics he was dealing with seemed due to age 
to show that but few even of the aged " °"^" 
die from natural decay, but "mostly from some 
specific disease, just like younger persons." ^ 
And he also said that the term " gradual decay," 
when used as an explanation of the cause of death 
of even old people, was " little else than an admis- 
sion of ignorance." ^ It is consolatory to have 
such high authority for believing that at the most 
advanced ages death is not due to age alone, but 
to disease ; because we always personify disease, 
we feel that we may escape it, we can fight it, 

1 Monthly Journal of Medical Science, August, 1853, p. 109. 

2 Op. cit., p. 110. 

1 B 


and often ovei^come it ; but age is the " carle 
dour" to whom we must all succumb. Hence a 
well-founded belief that disease and not age has 
been the cause of death, even at the most ad- 
vanced ages hitherto recorded, is fraught with the 
hope that science, if not luck, may make the 
patriarchal ages again our own, and that the man- 
tle of Methuselah may yet fall upon the shoulders 
of his nineteenth century successors. From Sir 
Robert's point of view there is no reason to regard 
this as impossible ; it even looms in the future as 
vaguely probable. But there is another point 
from which the lookout is not quite so hopeful. 

Many years ago an old writer recorded 
Yet as man's ,i_ , -,.,. ^ . j i • j • 

life is limited, ^^^ traditional experience of his time 
ac/e must have in these memorable words : " The days 
an important j- . i i 

eifect. ^^ °^^ years are threescore years and 

ten ; and if by reason of strength they 
be fourscore years, yet is their strength labour 
and sorrow ; for it is soon cut off, and we fly 
away." ^ The Psalmist does not set up three- 
score and ten as an age to which all must at- 
tain and which none may exceed, but merely 
states it as . the average limit of a full and 
complete life beyond which but few may pass, 
and that only "by reason of strength," which 
soon withereth away. 

1 Psalm xc, verse 10. 


And to-day the same story is repeated in the 
prosaic pages of the Registrar-General, with all 
the emphatic truthfulness of nineteenth century 
statistics. "Of 100,000 born in this country, it 
has been ascertained that one-fourth die before 
they reach their fifth year; and one-half before 
they have reached their fiftieth year. Eleven 
hundred will reach their ninetieth. And only two 
persons out of the 100,000 — like the last barks of 
an innumerable convoy — will reach the advanced 
and helpless age of one hundred and five." ^ Of 
the many millions born, only isolated exceptions 
attain great ages, and all are ultimately entombed 
in the urns and sepulchres of mortality, for " time 
like an overwhelming flood bears all his sons 
away," Tradition and statistics are thus agreed 
that few of those born attain the age of three- 
score and ten, and that beyond that age they die 
off so rapidly that seventy years may be prac- 
tically regarded as the extreme limit of even a 
long life. 

The life of the human body having thus an 
end as well as a beginning, it may be identified 

1 The above quotation -will be found at p. 24 of Smiles' worl?: 
on Thrift. London, John Murray, 1886. It is based on the 
Life-tables of the Eegistrar-General ; one of the latest of these 
makes one-half die before forty-seven. Vide Table B. , p. vii., 
Supplement to Annual Seport, 1885. 


with development, and all its phases inseparably 

linked with structural change.^ 
Lije is linked ^g g^j.g gQ j^ypj^ accustomed to asso- 

with develop- 
ment, and ciate development with growth merely, 
consequently ^^^^ -^ ^^^^^ ^ somewhat startling 

terminates _ _ 

necessarily proposition to connect it also with de- 
Tdea"^ cay, and but few of us are sufficiently 
educated to regard the development of 
the body as naturally ending only vrith its death.^ 
But this conception of the nature of development 
involves also the idea that as there are develop- 
mental phenomena initial in character, so there 
must also be similar phenomena which are ter- 
minal. And this brings vrith it matter for serious 
consideration ; for with it comes also the reflection 
that terminal phenomena may not always be re- 
stricted to that advanced age, to which alone 
they seem to be appropriate. For just as we may 
have a precocious development,^ so we may also 

1 " Jede Function 1st an mechanische Veranderungen der 
Substanz geknupft." — Virchow, Vier Seden iiber Leben und 
Kranksein, Berlin, 1863, p. 96. 

2 "Development and Life are, strictly speaking, one thing; 
ttiough we are accustomed to limit the former to the progres- 
sive half of life, and to speak of the retrogressive half as decay, 
considering an imaginary resting-point between the two as the 
adult or perfect state." — Huxley, British and Foreign Medical 
Beview, October, 1853, p. 305. 

' In the British Medical Journal for 6th February, 1886, 
p. 263, mention is made of a child three and a half years old 


have a premature decay. The development of 
man, in the only true sense of the expression, is 
a physiological process, dependent upon tissue 
change and not on years, and it may attain its 
natural termination before, as well as after, the 
conventional threescore and ten. To employ the 
expression " gradual decay " as an indication that 
death has occurred from age alone may often 

■who looked like a boy of ten or twelve years of age, and in 
whom puberty commenced at the early age of eighteen months. 
Many similar cases have been recorded by various authors from 
Seneca and Pliny downwards. Prematurity of development 
and precocity of growth are essentially distinct, though there 
is a close bond of union between them. Thus females not 
infrequently menstruate prematurely, but precocity of growth 
in that sex is so rare that Geoffrey Saint-Hilaire has only 
recorded two cases of combined precocity of growth and pre- 
maturity of development among females. Among males, on 
the other hand, many such cases have been recorded, and in 
them premature development of the genital organs is almost 
invariably associated with precocity of growth. Some of the 
cases recorded have been very remarkable. Sauvages, Hist, de 
VAcad. de 1666 a 1669, t. ii., p. 43, has given full particulars 
of a boy of six who was five feet high and broad in proportion. 
His growth was so rapid that it could almost be seen ; he had a 
beard, looked like a man of thirty, and had every indication of 
perfect puberty. He had a full, deep bass voice, and his ex- 
traordinary strength fitted him for all country work. At five he 
could carry any distance three measures of rye weighing 84 
pounds ; and at six years and a few months he could easily 
carry on his shoulders burdens weighing 150 pounds. But he 
did not become a giant as everybody expected ; he soon got 
feeble, deformed, and almost an idiot. Vide Histoire des 
Anomalies, par M. Isidor Geoffrey Saint>Hilaire, Paris, 1832, 
Vol. i., p. 197, etc. Vide also note 1, p. 12. 


enough be little else than " an admission of igno- 
rance," but to confound terminal phenomena with 
disease is worse; it is the unconscious revelation 
of an ignorance which is not admitted. 

The superficial observer, who fixes his attention 
upon gradual decay alone, sees but little of death 
from age; but he who recognizes the existence, 
the nature, and the importance of terminal phe- 
nomena, not only sees many deaths from age, but 
is often privileged to ward off for long the ulti- 
mate and inevitable end. The linking of growth 
with decay as part of the development 
Obsta princi- ^ striking views as to 

pus an inrqxyr- s^ tr t> ^ 

tant aid in the gradual evolution of terminal phe- 
proionaing ^^^^^^^ ^ ^ell as of the importance 

6y 6. 

of the early recognition of their first 
beginnings, and of the various modes in which 
they threaten life. Because in this matter per- 
turbative medicine and heroic measures can do no 
good, and may do much harm. To be of any use 
at all, we must put ourselves in nature's place 
and work as nature works.^ Here or there we 

1 Our lives are but a bunclle of consequences ; our present is 
but the outcome of our past. It is by trifling advantages, 
momentarily minute and imperceptible, that nature either 
worsens or improves the status of our vitality, and it is by 
securing these trifling advantages and turning them to the good 
of our patient that vital declension is averted, and chronic ail- 
ments remedied when that is possible. Vide Darwin, Origin of 
Species, and Balfour's Introduction to the Study of Medicine, 
A. & C, Black, 1865, p. 237. 


discover some trifling failure, which, like the 
" little rift ^vithin the lute," threatens serious dis- 
aster erelong; but appropriate remedies, timely 
applied, and long persevered with, may enable us 
to avert this disaster, and by the slow accumula- 
tion of petty advantages change the commence- 
ment of decay into the renewal of strength. In 
this way we shall more certainly prolong our life, 
and secure comfort in existence, than by the un- 
guents, the hot baths, and the elixir vitse, by which 
our forefathers sought to emoUiate the rigidity of 
age, and to add a fresh stock of vital force to that 
which was fast wearing away.^ 

We are born with potentialities, not powers; 
we have no store of energy upon which to draw, 
which may be wasted, and which must 
daily diminish. It is well for us that ^^ Inerg™ 
it is so, as we are all so apt to squan- 

1 The notion that desiccation is the cause of age, in the 
obnoxious sense of the word, was widely prevalent in early 
times. It gave rise to the story of the rejuvenation of Pelias 
in Medea's caldron, to which Lord Bacon refers as an instance 
of the utility of warm bathing in warding ofl age. Desicca^ 
tion as a cause of age is also referred to by Galen in his treatise 
De Sanitate Tuendo and De Marasmo ; and Haller actually 
states that fishes live long because their bones are soft and 
cartilaginous. Primm Lineae, § 972. Early indications of all 
the most modern ideas of preserving vitality by drinking hot 
fluids, clothing in woollen garments, and feeding on peptonized 
aliments, are to be found in Lord Bacon's Historia Vitm et 
Mortis, Spalding's edition, London, 1858, Vols. ii. and v. 


der our energy in work or play, or to have it 
wasted for us by disease, that had we only a fixed 
amount on which to draw, but few of us would 
live to old age, and not so many as now even 
to middle life. As it is, all our energy comes 
from without ; we take it in as food in the Poten- 
tial form, and we transform it into the Kinetic 
form by means of the oxygen circulating in our 
blood. Every act of life, every pulse that beats 
within us, every thought we think, involves this 
transformation of energy, even though no appar- 
ent movement indicates the presence of voluntary 
life. That we may continue to live, the products 
of this chemical action must be removed, and the 
used-up waste replaced by fresh oxidizable mate- 
rial; and our organism is so constructed that for 
a time this goes on continuously. The 
latest definition of life is based upon 
these facts, for "the continuous adjustment of 
internal relations to external relations " ^ is obvi- 
ously but a concise statement of the conditions 
necessary for the continuous manifestation of liv- 
ing action, and not a definition of life itself. 
Though it therefore fails the metaphysician, this 
definition is practically sufiicient for the physician, 
who deals only with the physics involved. And 

1 The, Frinciples of Biology, by Herbert Spencer. Williams 
and Norgate, London, 1865, Vol. i., p. 80. 


we may also accept the converse, that death is the 

result of a "failure to balance ordi- 

Death defined. 
nary external actions by ordinary in- 
ternal actions." ^ But food and oxygen remaining 
plentiful, as we may assume they ordinarily do, 
there seems no reason why assimilation, oxidation, 
and the genesis of force should not go on forever, 
or until some cataclysmic change in our environ- 
ment should disturb the balance of internal and 
external actions. It is within ourselves, therefore, 
that we must seek for that change which causes 
these processes of assimilation, oxidation, and the 
genesis of force, gradually to fall out of corre- 
spondence with the relations between oxygen and 
food, and the absorption of heat bj'' the environ- 
ment, which happens in old age, and is the cause 
of death by natural decay .^ 

In days gone by the hypothesis of a gradual 
decrease of vital force was supposed to explain the 
enigma of gradual decay .^ But vital 
force is but another name for the sum j,jYozVo"ce. 
of all the vital actions of the frame ; 
and to point out that these are decreasing is, 

1 Spencer, op. cit., p. 89. 

2 Spencer, op cit., p. 88. 

8 " La gene de I'influence vital s'accroit sans cesse." — Cata- 
nis. "That considerable differences exist in the stock of vitality 
originally imparted to the frame in different individuals cannot 
be doubted, some being destined to a shorter, and others to a 


indeed, to indicate that the organism is dying, but 
is no explanation of why it dies. Failure in the 
genesis of force is only an indication of failure in 
oxidation or assimilation. 

So, too, impoverishment of the blood, which has 

been regarded as the cause of the gradual failure 

in the aged,^ is itself due to imperfect 

Causes of fail- assimilation, and leads to imperfect 

ure in the gen- ■ i , • i " ^ j -i 

esis of force, oxidation and consequent failure m 

the genesis of force. Imperfect assim- 
ilation is, doubtless, one of the most important 
links in the chain of causes which lead to the 
general decay of the bodily frame. The difficulty 
is to say where this chain begins ; for all the func- 
tions of the body are so linked together that there 
is not one of them which can be called primary, 
upon which, when it fails, may be laid the blame 
of initiating the decay of all the others.^ 

The more, indeed, we investigate the phenomena 
of decay, the more clearly do we see that this 
does not arise from any failure of the sources of 
potential energy, but solely from the inability 

longer, term of existence." — Eoget, article "Age," in the 
Cyclopedia of Practical Medicine, etc. 

^Vide articles on "Age," in the Cyclopedia of Anatomy 
and Physiology, by Symonds, p. 82 ; and in the Cyclopedia of 
Practical Medicine, by Roget, p. 39. 

2 Roget, loc. cit. ; and Whytt, On Vital Motions, Edinburgh, 
1751, p. 270. 


of the organism to make use of those presented to 
it, because it has itself become effete as the direct 
and necessary result of development. 

In early life the body grows through the abun- 
dance of the fluid food, with which every part is 
flushed. The characteristics of the 


systemic circulation upon which this tics of the dr- 
flushing depends are, that the ampli- cuiationin 
tude (calibre) of the large arteries is 
great in comparison to the size of the heart, and 
also to the length of the body. Hence there is a 
low blood pressure and a rapid pulse-rate. The 
large amount of fluid in the tissues, the abundant 
supply of nutriment, and the low blood pressure, 
coupled with the shorter time in which the whole 
circuit of the vascular system is traversed,^ all 
favour the diffusion of the blood-plasma and the 
rapid growth of the body. These conditions pre- 
vail during early life, but are most marked during 
the first year. During early life the whole body 
grows in every part, but the growth of the arteries 
in calibre does not keep pace either with the 
growth of the body in length, or with the growth 
of the heart in amplitude and strength. The nat- 
ural result is a gradual rise in the blood pressure, 
and an equally gradual slowing of the pulse-rate 

1 Twelve seconds as against twenty-two in the adult. Vide 
Foster's Physiology, 1883, p. 685. 


as growth and age increase, until in early man- 
hood growth is completed, and the blood pressure 
reaches its highest norm. At this period the 
whole organism is full of life and vigour, and is at 
its best in respect of its capacity for bodily and 
mental exertion.^ But as development progresses, 

1 Vide Die AUersdisposition, by Dr. P. W. Beneke, Marburg, 
1879, pp. 7, 12, 14, and 18. About this time two events, the 
access of puberty and the cessation of growth, have a most 
important influence in the story of development. Beneke refers 
the access of puberty to the cessation of growth. The capillary 
system, during the second stage of life (7-15), ceases to grow 
as heretofore ; the brain and large glands have attained nearly 
their full development, and the blood pressure, still rising in 
the whole arterial and capillary system, finds its outlet in the 
development of the sexual organs, the glands of the skin, and 
the growth of the hair always associated with maturity (op. cit. , 
p. 14). This explanation of the physics of development seems 
adequate enough so far as it goes. The great difficulty is to 
account for the cessation of growth at all in any part of the 
body. Geoftroy Saint-Hilaire (pp. cit, vol. i.) has some very 
pertinent and interesting remarks on this subject. He points 
out that dwarfs are imperfect individuals, usually impotent; 
their growth and development have both been arrested. But 
inasmuch as puberty alone puts an end to the growth of man, 
a dwarf may recommence his growth at any time, even up to 
old age ; and Saint-Hilaire states that he himself had observed 
several instances of this (p. 190, note). Giants, on the other 
hand, are those in whom growth has continued because their 
sexual organs have been slowly and incompletely developed. 
Giants are mostly impotent, always feeble, feminine in aspect, 
and usually very shortlived (p. 192). In precocious children, 
the rapid growth being early directed to the sexual organs, the 
individual ceases to grow ; from a gigantic child he may become, 
if he lives, a man of but moderate bulk (p. 192). So it may 


the arterial coats slowly undergo a change of 

structure, by which they lose their 

, ,. ., , , in Changesinthe 

elasticity, and become gradually con- vascular sys- 

verted into more or less approximately *^™ through 

rigid tubes.^ The effect of this loss 

happen that a child with very active nutrition may become 
, either an imperfectly developed giant, or an early developed (pre- 
cocious) youth of moderate hulk (pp. 193, 194). Saint-Hilaire 
merely states these as facts, without in any way attempting to 
account for them. He points out that there are various races 
of men famous for their hulk and stature, and others remark- 
able for their diminutive size ; and that though food and other 
accidents of environment have an acknowledged influence in 
promoting and hindering growth, yet those races of varying 
size unquestionably owe more to heredity (however acquired) 
than they do to abundance of food, and a comfortable, easy 
life, or the reverse (pp. 240, 241). It is the physics alone of 
growth that concern us : could we know these perfectly, it would 
suffice ; meanwhile as these physics are closely involved with the 
progress and cessation of growth, it would be of great impor- 
tance to discover why we ever cease to grow. Herbert Spencer 
says that growth is arrested "because the excess of absorbed 
over expended nutriment must, other things equal, become less 
as the size of the animal become greater." — Principles of 
Biology, Vol. i., p. 122. If this were the true reason, we should 
all be more nearly alike in size than we are. Moreover, though 
this seems a good enough reason for an animal ceasing to live 
when it attains a certain bulk, and thus seems applicable to 
giants, and explanatory of their short lives, it does not seem 
to be a sufficient reason why we should ever cease growing 
before we reach that extreme bulk, nor does it give any expla- 
nation of the very peculiar relations subsisting between growth 
and sexual development. ' ' 

1 " One common feature of old age is the conversion by such 
a change " — that is, by the replacement of a structured matrix 


of resilience in the arterial coats is, that while 
these coats yield as formerly to the advanc- 
ing blood-wave, they yield more slowly, and 
they do not recover themselves, so that the lu- 
men of the arteries undergoes a gradual dilata- 
tion. The heart at the same time tends to fail, 
senile atrophy begins, and in the midst of our 
fullest life Death himself lays his finger upon alP- 
our organs. From the dilatation of the arteries 
there is a tendency to lowering of the blood press- 
ure ; and to this failure of the blood pressure has 
been ascribed that obsolescence of the capillaries 
which is the cause of the dry and wrinkled skin, 
the gray hair, and the cessation of the sexual func- 
tions, and which is so evident on the anatomical 
investigation of the organs themselves.^ The 
result of this withering of the capillaries is, ac- 
cording to Beneke, by diminishing their area, to 
increase the peripheral resistance to the onward 
flow of the blood, and thus to raise the blood 
pressure within the arteries themselves, so that, 
notwithstanding dilatation of these vessels, the 
blood pressure in age is always greater than it is 
in early youth. This view of Beneke's is not, 
however, quite consistent with the physical facts ; 

by amorphous material — " of the supple, elastic arteries into 
rigid tubes."— Foster, op. cU., p. 690. Vide also references 
on p. 20. 1 Beneke, op. cit., p. 24. 


circumstances being alike, the increase in the 
arterial capacity would undoubtedly lower the 
blood pressure within them ; but the circumstances 
of age are by no means those of youth. In youth 
the relatively large calibre of the arteries has no 
ill effect on the circulation, because though the 
blood pressure is not great, it is perfectly sufficient 
to keep up a steady and continuous flow into the 
capillaries. In age, however, the case is different ; 
the loss of arterial elasticity, while it throws a 
greater strain upon the heart itself, makes the out- 
flow into the capillaries approximately intermit- 
tent, and thus lowers the blood pressure within the 
capillary area, though it still remains high within 
the arteries themselves.^ The cessation of active 
growth makes a large network of capillaries un- 
necessary, and the fall of the blood pressure within 
these vessels permits many of them to obsolesce. 
The result, therefore, is identical, though the 
steps by which it is reached are not exactly as 
Beneke has put them. By the time the heart has 
succeeded in permanently dilating the inelastic 
arteries, and has restored them to their former 
relative magnitude, the increase of the peripheral 
resistance, due to the withering of the capillaries, 
is sufficient to prevent any material lowering of 
the blood pressure from this cause. By and by, 
1 Foster, op. cit., p. 132. 


however, this is gradually brought about by weak- 
ening of the heart through failure of the genesis 
of force, due to failure of assimilation arising from 
withering of the capillaries in the skeletal muscles, 
as well as in all the glands of the body. 

Decay is thus the necessary and final stage of 
development ; and though it may not be possible 
to put a finger upon any special function or struct- 
ure, and to say. Here decay commences, yet erelong 
we can positively say, This is the line along which 
decay is marching, and here is the structure in which 
we can earliest detect the withering effects of age. 

From our earliest days the growth of our frame 
is accompanied by a gradual condensation of tis- 
sue, till the gelatinous pulp of the primitive 
embryo is converted into the withered old man. 
Every tissue partakes of this change : the skin 
becomes dry, flaccid, and wrinkled; the bones are 
denser and more brittle; the muscles participate 
in the condensation incident to the cellular tissue, 
which enters so largely into their composition; 
the muscular fibres themselves are more rigid, 

diminished in bulk, and impaired in 

Tithonus a ^ 

true type of Contractility, so that they are less read- 

pro^tracted Hy ^nd less powerfuUy excited by 

stimuli.^ Hence the shrunk shanks, 

tottering gait, and withered aspect of the aged 

I Roget, op. cit., p. 40. 


man which have crystallized into the figure of the 
fabled Tithonus as the classic representative of 
protracted age.^ It is only in fable, however, that 
Tithonus suffers from the burden of undying age ; 
in real life his frailties promote his euthanasia. 
Worn with his weary tramp through 
life, no longer able even to totter -f^^a^^i/e 

' ° . Tithonus 

about, Tithonus at last lays him down ^les. ms 

to rest. Partly from the loss of the deathisatyp- 

ical death 
stimulating effect of the little exercise from age. 

he was able to take, and partly from 
a similar cause to that which has occasioned the 
wasting of his skeletal muscles, his powers of 
assimilation give way. His blood becomes dimin- 
ished in quantity and defective in quality ; the 
brain centres for relative and for organic life get 
badly nourished; the genesis of force becomes 
more and more imperfect ; slight wandering delir- 
ium sets in, and death from asthenia speedily fol- 
lows. Scenes anticipatory of the future, more 
often memorial of the past, flit like dreams 
through the failing consciousness, and the weary 
mortal occasionally dismisses himself with some re- 
mark bearing on his future or his past. " Adsum" 

1 His wife, Aurora, obtained from Jupiter the gift of immor- 
tality for him, hut forgot to ask for perpetual youth ; hence, 
Horace says, "Longa Tithonum minuit senectus." — Lib. II., 
carmen xvi., 1. 30. 


has been the final utterance here, the fitting pre- 
lude to hereafter. Charles Abbot, the first Lord 
Tenterden, when dying, raised himself from his 
couch, and saying, with all his wonted solemnity, 
" Gentlemen of the jury," fell back and expired ; 
and the gathering glooms of death drew from the 
great schoolmaster Adam the pathetic and appro- 
priate farewell, " It grows dark, boys, you may ' 
go." "The great difference," says Bichat, "be- 
tween death from old age and death from a sudden 
seizure, is that in the former death commences at 
the periphery and terminates at the heart — the 
empire of death begins at the circumference and 
ends at the centre ; while in the latter death com- 
mences at the heart and spreads over the body 
generally — death begins at the centre of vitality, 
and gradually extends to its outmost bounds." ^ 
It is impossible to imagine any mode of dying to 
which Bichat's description of death from age could 
be more applicable than it is to that just described. 
It is the typical mode of dying from gradual de- 
cay. Except as to perpetual youth, Tithonus is 
no myth, and his mode of dying, though not the 
lot of every one, cannot fail to be recognized, and 
is not readily forgotten.^ It is a mode of dying 

1 Becherches physiologiques sur la vie et la mort, Paris, 1805, 
p. 151. 

^ An admirable and most pathetic description of death from 


peculiar to advanced age ; yet, even in old age, 
men die more commonly from accident or disease 
than from simple decay. Not because develop- 
ment has not the same course in every 
one, and tends always to the same -^se must be 

•' measured by 

end ; but because those tissue changes, tissue change, 
which mark the progress of develop- «»'«»<'« ^^^ 

^ ° ^ years. 

ment from the cradle to the grave, 

intensify after middle life all the dangers of acute 
diseases, and by accentuating any latent organic 
weakness or structural defect, inherited or ac- 
quired, often cause those to die from age who 
have scarcely begun to think themselves old. 
Tithonus the aged succumbs at last from failure 
of the genesis of force. He dies from asthenia 
due to failure of oxidation following failure of 
assimilation, primarily induced by changes in the 
circulatory" system. We cannot trace the changes 
in the capillaries and arteries beyond the vessels 
themselves : we know not the cause of these 
changes. But it is an advantage to know, and 
there is a general consensus of opinion on this, 
that the arterial system, which leads the van in 
the development of the body, is also that upon 

age is to he found in the Book of Ecolesiastes, Chapter xii. 
The authors of the Eevised "Version have somewhat added to 
the pathos of this description by substituting the word " caper- 
berry" for "desire." 


which the finger of decay is earliest laid.^ By- 
watching the development of this system and its 
relations to the heart and other organs, we are 
timeously warned, and are often able successfully 
to oppose the beginnings of evil. To recur to 
Bichat's simile, though we cannot prevent the sap- 
ping of the outworks, we can reinforce the citadel, 
and thus we are often able to postpone the ulti- 
mate surrender. True, we cannot hope in this way 
to provide an Agerasia, nor even to restore the 
patriarchal ages ; but we can assuredly diminish 
the number and intensity of those side issues 
which so often bring life to a premature termina- 
tion. We can greatly lessen human suffering, and 
we may put it in the power of many more nearly 
to attain the norm of life, which, according to 
Beneke, is from ninety to one hundred years.^ 

1 Vide articles on "Age" in the Cyclopedia of Practical 
Medicine, p. 38, and in the Cyclopedia of Anatomy and Phys- 
iology, p. 77. Vide also Gimhert, "Memoire sur la structure 
et sur la texture des arteres," Journal de V Anatomic, Vol. ii., 
p. 648. Valerie Sohiele-Wiegandt says: "In bezug auf das 
Alter ergiebt sich folgendes Gesetz sowohl bei Mannern als 
auch bei Frauen nehmen im Grossen und Ganzen, entsprechend 
den hoheren Altersperioden, in alien arterien umfang und dicke, 
respective media und intima, allmahlich steigend zu" {Vir- 
chow^s Archiv., Bd. Ixxxii., S. 36) ; and Eoy has found that 
sometimes before, and certainly always after, middle life, the 
arteries begin to lose their elasticity (Journal of Physiology, 
Vol. iii., p. 125, etc.). 

2 Op. cit., S. 26. 



Two organs largely escape the effects of normal 

failure — the brain and the heart. Goethe, Von 

Humboldt, Leopold Ranke, Mrs. Som- 

Heart and 
erville, and Thomas Carlyle, are mem- brain largely 

orable examples of those who have done ^^'"'p^ senile 


excellent brain work at very advanced 

periods of life; and, indeed, the wisdom of age 

would never have become proverbial had the brain 

not been observed to functionate with its wonted 

integrity even in hoar age. In typical death from 

age the mind can scarcely be said ever to fail ; it 

wavers, indeed, amid the gathering glooms of 

death, but till then its acuteness and energy are 

often scarcely diminished. The brain 

, , , 1.1 The mainte- 

remains vigorous to the last, because ^^^.^f^rai^ 
its nutrition is specially provided for. poioer spe- 
At or after middle life, though the If^^^fJ"' 
arteries of the body generally lose 
their elasticity and become slowly dilated, the 
internal carotids continue to retain their pristine 



elasticity and calibre,^ so that the blood pressure 
within the cerebral capillary (nutritive) area re- 
mains normally higher than within the capillary 
area of any other organ in the body ; the cerebral 
blood paths are thus kept open, and the brain 
tissue itself is kept better nourished than the 
other tissues of the body. 

The corollary from this is important: brain 
failure, not being a necessary characteristic of age, 
must always be looked upon as an indication of 
local malnutrition, and for this cardiac failure or 
arterial atheroma are most often to blame. In the 
one case, improvement may be expected from treat- 
ment; in the other, the failure of treatment but 
confirms the provisional diagnosis. 

As for the heart, this organ has long been 
The heart is known to be hypertrophied in all old 
always found people. M. Bizot, in his well-known 
at advanced papcr entitled " Recherches sur le 
'^ses. CcEur et le Systeme Arteriel chez 

I'homme," ^ tells us that " old age is in both 

1 Beneke, op. cit., p. 24, "Die grossen Arteriellen Gefas- 
stamme erfahren dagegen eine immer mehr zunehmende Er- 
weiterung, und erreichen, mit ausnahme der Carotides commu- 
nes, relativ zur korperlange eine noch betraohtlicher Weite, als 
im ersten Lebensjahre." Also, op. cit., p. 75; and Constitu- 
tion und Constitutionelles Kranksein des Menschen, von Dr. 
F. W. Beneke, Marburg, 1881, p. 42. 

2 Vide Memoires de la Societe Medicale d' Observation, Tome 
premier, Paris, 1837, p. 262. 


sexes that period in which the heart attains its 
greatest dimensions," so that if it be correct " to 
compare the size of the heart at thirty years of 
age to that of the fist of the subject, at sixty the 
heart will be found to be much larger if it is not 
abnormal." ^ 

Charcot, in his " Lectures on Senile Diseases," ^ 
says that, unlike every other organ in the body 
but the kidney, the heart preserves even in old 
age the dimensions of middle life ; and he adds 
that in some old people "the heart may even 
undergo a real hypertrophy." 

Cohnheim is of a similar opinion ; he says, " The 
heart of very old persons does not, as a rule, par- 
ticipate in the general atrophy of the body, and 
especially of the muscles, but rather increases in 
mass and volume." ^ 

Beneke's experience, on the other hand, sufficed 
to convince him that only those reach advanced 
life who have been originally possessed of large 
and strong hearts.* According to Beneke age is 

1 " Si done a trente ans le coeur doit avoir le volume du 
poing du sujet, a soixante il doit etre plus volumineux, sous 
peine d'gtre dans une condition anormale. La vieillesse est, 
dans les deux sexes, Tepoque de la vie a laquelle le cceur ofire 
le volume le plus considerable " {op. cit., p. 275). 

2 New Sydenham Society's Translation, p. 28. 

8 Lectures on General Pathology, New Sydenham Society's 
Translation, Vol. i., p. 106. 

* Die AUersdisposition, p. 24. " Wenn die von mir auf 


not a possible inheritance of all, but only of a 
select few destined to it from birth. I myself, 
however, have seen too many weak hearts, and 
even hearts mechanically defective, attain advanced 
age to regard this idea as even approximately true. 

Charcot distinctly recognizes the senile hyper- 
trophy of the heart as the legitimate result of the 
senile alteration of the arteries. But he limits 
the change to " some old people," and regards it 
as pathological.^ 

Bizot, on the other hand, states explicitly that 
this senile hypertrophy of the heart occurs in all 
without exception ; that it is mainly limited to the 
left ventricle, though the right ventricle also 
shares in it to a limited extent; and that it is 
invariably associated with dilatation of the arte- 
rial system and thickening of the arterial walls. 
These changes affect every one, man and woman 
alike, and continually increase as age advances.^ 
But changes which happen to every one, and con- 
tinually progress as age advances, form part of 
our development and are physiological, and not 

Tab. I, gezeiohnete curve (des Herzensvolum) in den 70ger 
Jahreu noch wieder sine Hebung zeigt, so lasst dieselbe kaum 
eine andere Erklarung zu als dass diese hohe Altersstufe tiber- 
haupt nur von im allgemeinen kraftigen Naturen erreicht vfird, 
und dass diese auch von Haus aus schon ein grosseres Herz- 
volum besitzen." 

1 Loo. cit. 2 Vide op. cit., pp. 275, 286, 288, 301, etc. 


pathological. They may often enough be asso- 
ciated with pathological alterations of the arterial 
coats, but this is not always the case even at the 
most advanced ages, and the merely normal loss 
of arterial elasticity is quite sufficient to account 
for the change in the structure of the heart. 

The normal elasticity of the arterial coats con- 
verts the intermittent blood flow from the heart 
into a continuous flow into the capillaries, and 
when this elasticity fails, the outflow into the 
capillaries becomes approximately intermittent, the 
blood pressure within their area falls, many of 
them obsolesce, and the most obvious, if not quite 
the earliest, of our senile changes are initiated. 
On the other hand, this intermittent outflow from 
the arteries accumulates the blood within them, and 
raises the intra-arterial blood pressure.^ The result 
of this is that the left ventricle is „,,,„„^,,,,^ 
called upon for extra exertion, in vigour in the 

, , 1 ■ ,1 j_ • 1 1 senile heart. 

order to bring the arterial and venous 
blood pressures and the velocity of the circula- 
tion to their normal values. Fortunately the 
heart always works so well within its powers, that 
in health it readily responds to any call of this 
character.^ The response of the left ventricle to 

1 Vide antea, p. 15. 

2 Vide Balfour's Clinical Lectures on Diseases of the Heart 
and Aorta, Churchill, London, 1882, second edition, p. 84, and 
p. 137, note. 


this call is necessarily followed by the flushing of 

the myocardium at each pulsation with blood at a 

pressure considerably above the normal, hence — 

other things being equal — metabolism is more 

complete and nutrition more perfect. Add to this 

that according to Leichtenstern ^ the hsemoglobin 

is always found to be increased after sixty, and 

we see that the conditions at and after middle 

life are — in health — most favourable for the 

gradual development of hypertrophy of the heart, 

and especially of the left ventricle. Nay, so 

favourable are those conditions that weak hearts, 

and even hearts mechanically defective, are able 

to profit by them, so that many hearts at seventy 

are stronger and better fitted for the discharge of 

their functions than they were at sixty. The 

changes in the arteries due to age pro- 
Senile vascu- ^ ■, t ■ -i i -, e 

lar changes ceed slowly, imperceptibly, and so far 

proceed imen- g^g ^^ individual himself is concerned, 

unconsciously. If the heart responds 

normally to the call for extra exertion demanded 

of it, the individual gradually descends into the 

vale of years quite unconscious whether he has 

a heart or not. If this knowledge is forced upon 

him, trouble is not far off. 

Various circumstances may bring to mind that 

1 Untersuchungen uber den Hmmoglohingehalt des Blutes in 
gesunden and kranken Zustdnden, Leipzig, 1878, S. 29. 


we have a heart; its function maj^ be disturbed 
by an excessive strain thrown on the myocardium 
by an early and excessive development of arterio- 
sclerosis, the arteries in early life being sometimes 
as hard and tortuous as they are ever found to be 

even at the most advanced age. Ven- „ 

° Uauses of 

tricular embarrassment is produced by trouble to the 
whatever increases peripheral resist- ««»"« '»««'"'• 
ance. We have, therefore, to reckon not only 
with the alterations in the elasticity and structure 
of the arteries, but also with the permanent con- 
traction of the vascular area due to capillary 
obsolescence, as well as with those temporary con- 
tractions arising from reflex causes of various 
origins, which not only embarrass the circulation, 
but also give rise to sundry symptoms of very 
serious import. Moreover, peripheral resistance 
is greatly increased by any augmentation of the 
quantity of the blood, whether that be caused by 
plethora or hydrsemia, and, as we can readily 
understand, it may be notably affected by the con- 
dition of the vascular environment.^ 

In estimating the various causes which hinder 
the passage of the blood from the arteries to the 

1 Vide Text-book of Pathology, by D. J. Hamilton, M.B., 
etc., London, 1889, Vol. i., p. 630 and p. 694. Bonders seems 
to have been the first to direct attention to the importance of 
the vascular environment in relation to blood pressure. Vide 
Physiologie des Menschen, Leipzig, 1856, Vol. i., S. 169. 


veins, and thus increase the intra-arterial blood 
pressure, we are too apt to overlook the condition 
of the tissues generally. We figure to ourselves 
the blood going its round through arteries, capil- 
laries, and veins, as it were through naked tubes, 
forgetting that nutrition is extra-vascular, that the 
tissues are always flooded with blood-plasma, and 
that this fluid diffuses the elastic pressure of the 
tissues, and binds it to that of the arterial wall. The 
tissues themselves lose their elasticity through age, 
— like the arteries, — and this cannot be renewed. 
But the influence of the environment depends not 
so much upon this as upon the amount of fluid 
filling the interspaces of these tissues, and this 
varies both as to quantity and quality according 
to the state of the circulation, the quality of the 
blood, and the integrity of the secreting organs 
upon which this quality depends. 

On the side of the heart embarrassment is 
brought about by all those circumstances and con- 
ditions of life which of themselves weaken that 
organ, and consequently intensify the action of 
those hindrances that have just been referred to. 

Acute diseases weaken the heart by interfering 
with its nutrition and exhausting its nervous 
energy. Sudden critical or precritical cardiac col- 
lapse is a thing we are all well acquainted with. 
Sudden death from cardiac failure that not infre- 


quently follows any abrupt exertion — such as 
sitting up or getting out of bed — during convales- 
cence from acute disease, is also not unknown. 
But tbere is a third mode of dying from the heart 
after acute disease, which is neither so common 
nor so generally recognized ; in this some trifling 
exertion, undertaken before the heart has had 
time to reaccumulate sufficient energy, starts an 
ingravescent asthenia from which there is no 

Death from the heart, in any of those modes, 
is naturally most apt to occur after middle life, 
first because the cardiac energy is then more 
readily exhausted, and second because its action 
is already embarrassed, by one or more of the 
causes of peripheral resistance just alluded to. 

Apart from acute disease, which, as we see, is 
more apt to initiate death, rather than heart trouble, 
chronic disease has an influence in this direction, 
but chiefly those forms of it which weaken the 
myocardium or impoverish the blood without 
materially diminishing the amount of the circu- 
lating fluid. Long-continued dyspepsia is well 
known as a common cause of heart trouble ; 
sometimes it is only a symptom, but often it is a 
cause as well. 

Loss of blood from any cause, either sudden 
and considerable or more continuous and in less 


amount, weakens the myocardium and leads to 
heart trouble, which worsens as hydrsemia is estab- 
lished. Any other discharge which has a similar 
effect is followed by a similar result. Sexual 
excess has an equally ill effect, probably quite 
as much from loss of nervous energy as from any 
drain on the system. 

Over-indulgence in food induces plethora — a 
most dangerous condition for any one with a weak 
heart. Plethora produces corpulency and loads 
the tissues with fat ; this weakens their structure, 
and by making the cardiac muscle less fit for its 
function, it intensifies the action of the peripheral 
obstruction it helps to cause in inducing heart 
trouble. The abuse of stimulants and narcotics 
is a most fruitful source of senile heart trouble, 
and when conjoined with gluttony the combina- 
tion is the most potent source of heart trouble 
we could have. 

Sudden, violent, or unduly prolonged exertion 
is a fruitful source of heart trouble at all ages, but 
it acts with tenfold efficacy after middle life, and 
is a not infrequent cause of an abrupt termination 
to life itself.^ 

1 The influence of overwork and strain in producing cardiac 
dilatation has long been known, and has been well described 
by Dr. Thomas Clifford AUbutt in Vol. v. of St. George's 
Hospital Beports, 1870 ; Dr. J. M. Da Costa, American Journal 
of Medical Sciences, January, 1871, p. 17 ; A. B. R. Myers, 


Lastly, emotion of every kind has long been 
recognized as having an important influence on 
the heart's action and functions, and as a factor 
we dare not neglect in investigating the etiology 
of cardiac disease, and especially of sudden car- 
diac failure. 

Inhibition of the heart's action by violent emo- 
tion is a well-known though unusual cause of 
sudden death; and contrary to what one would 
expect, joyous emotions are much more fatal than 
grief or sorrow.^ 

But such a tragedy as this is infinitely rare in 
comparison with the pathetic manner in which life 
is every day shortened by the petty troubles, anx- 
ieties, and worries which are of daily occurrence. 
The less intense but more persistent emotion 
keeps up a continual inhibition of the heart's 
action in a lesser degree. This impairs the ven- 
tricular systole, and coupled with those vascular 
conditions which after middle life favour cardiac 
dilatation, often precipitates heart trouble in those 

surgeon, in Etiology and Prevalence of Disease of the Heart 
among Soldiers, London, 1870. Also in Zur Lehre von der 
Ueheranstrengung des Herzens, von Johannes Seitz, M.D., 
Berlin, 1875 ; and in Die HerzkranTcheiten in Folge von Ueher- 
anstrengung, von E. Leyden, Berlin, 1886. 

1 For many instances of sudden deatli from emotion, vide 
A Treatise on Experience in Physic, London, 1772, Vol. ii., 
p. 268. This is an anonymous translation of a -work by Johannes 
Georgius Zimmermann. 


who might otherwise have escaped. There are 
few of us who have been in practice for even but 
a short time who have not had occasion to note 
the development of serious cardiac symptoms from 
the trouble arising out of untoward domestic 
affairs, the worry of an unsuccessful business, or 
even the wear and tear of a too successful business 
which has outgrown the physical powers of its 

The morbid anatomist finds after death, and 
ascribes to senile degeneration, many conditions, 
such as pigmentary involution, fatty degeneration, 
aneurism, and rupture of the heart.^ But none 

^ E. Leyden, pp. czY., p. 47, says : "Die alten Aerzte wussten 
es sehr wohl, das Gemiithsbewegungen und Leidenschaften, 
Zom, besonders aber Gram und Schmerz Herzkrankheiten zu 
erzeugen im Stande sind. Die neuere Medizin hat diese Er- 
fahrung ziemlich vernachlassigt, doch wird jeder erfahrener 
Praktiker Beispiele davon anfiihren konnen. Icb selbst habe 
eine Anzahl soloher Ealle beobachtet. Sie haben in ihren 
Symptoinen und ihren Verlaufe eine auffalige Uebereiu- 
stimmung mit den Fallen von Korperlicher Ueberanstrengung 
des Herzens und Man konnte versueht sein sie als psychische 
Ueberanstrengung jenen an die Seite zu stellen. Die Analogie 
besteht sowohl darin, dass das auffaligste Symptom, nahmlioh 
die Arythmie und die Herzdilatation sich ebenfalls in Folge 
von psyohischen Einfliissen entwickeln, als auch darin, dass 
zwei stadien der Krankheit unterscheiden werden konnen, das 
erste der Herzerithismus, das zweite die organisohe Herzdilata- 

''■ Vide Hamilton, op. cit, pp. 582, 587, etc. Sclerosis and 
waxy degeneration are sometimes reckoned as senile changes, 
but the one is the result of inflammation, and the other of a 


of these morbid states have any pathognomonic 
symptoms ; it is only when they affect the heart's 
action that they come under the cog- 
nizance of the physician. It is much sion of the 
the same with the senile heart; its ««»«« ''«°'-'- 
essential lesion is a weakened myocardium, rarely 
without dilatation of the cavities. This dilatation 
is caused by overstrain, occasionally from actual 
over-exertion, but far more frequently slowly in- 
duced by causes which are partly physical and 
partly nervous in their origin. 

The symptoms of this weakened myocardium 
vary somewhat in each case, but they have a 
generic similarity in all. Precordial anxiety is 
usually what is first complained of, „ , 

•' ^ ' Symptoms of 

and however indefinite this may sound the senile 
it is a source of extreme distress to ^"'' ' 
the patient. Breathlessness, pain, or cardiac irreg- 
ularity, in one or other of its many forms, are also 
early symptoms, and sometimes the case is accent- 
uated by the conjunction of two or more of these 

As these symptoms may all be present in the 

general blood disorder ; and both may occur at any age. Ham- 
ilton, op. cit. , p. 588, etc. Vide also Etude, sur le Oosiir Senile, 
par le Dr. Ernesto Odriozola. Paris, 1888. Huber, however, 
inclines to reckon sclerosis of the myocardium as a purely 
senile disease, seeking its origin in arterio-sclerosis alone. 
Vide Archivf. Patholog. Anatomie, Bd. Ixxxix., 1882, S. 236. 


absence of any definite signs of any cardiac lesion, 
they are often grouped under the somewhat indefi- 
nite term of a Nervous Heakt. A term appli- 
cable enough if only employed to signify that these 
symptoms are brought about through the agency 
of the nervous system, but quite incorrect if em- 
ployed to suggest that these symptoms have no 
basis of physical change in the heart itself. 

In its later stages the senile heart, in one of its 
forms at least, is the Luxus Herz of German 
authors, the Gouty Heart of our writers. The 
term "gouty heart" is indeed equally applicable to 
its early as well as to its later stages, inasmuch as 
those vascular changes which superadd the gouty 
element proceed fari passu with those which origi- 
nate the senile heart itself, and are closely linked 
with them. It is convenient, moreover, to have 
such a term to apply, as few people object to be 
called gouty, though many resent being called 
either nervous or old. 



It may be accepted as an axiom that all cardiac 
symptoms complained of after middle life, that can- 
not be distinctly referred to some evi- 
dent disease, or to some affection of the ^'^^^"^ <"" ''^^- 

ative weak- 

cardiac mechanism due to disease, may ness of the 
be regarded as originatino; in actual or ™yoca?-&mn, 

^ ^ ^ the ongm of 

relative weakness of the myocardium, the symptoms 
These symptoms may be of the most fJJ^^ "'""' 
varied character. 

The heart working easily within its powers has 
its work — actual or relative — gradually increased, 
till it reaches a point when it makes itself felt. No 
longer unconscious of the existence of a heart, the 
individual becomes uneasily cognizant of the pres- 
ence of that organ. The earliest indi- „ ^ .,. 

o Definition of 

cation of this is a feeling of emptiness precordial 
and uneasiness in the left chest, very "™^'^"-'- 
aptly expressed by the term Precordial anxiety. 
If we examine the heart at this stage, we find 


on palpation that any sensation of pulsation in 

, ^ the cardiac area is but feeble, while 
Signs to be 

found at this the apex beat itself is at the best weak 
stage. ^^^ ^^^ ^^ quite imperceptible ; the 

percussion dulness is normal ; on auscultation the 
sounds are normal, or, if there is any change at 
all, the aortic second is accentuated. These are 
indications of weakness of the myocardium, and 
the accentuated aortic second, if present, is an 
indication that to the normal loss of arterial elas- 
ticity there has been superadded a dilatation of the 
ascending part of the aorta.^ Being weak, the 
heart is erethistic, it is irritable, and its action is 
readily excited or deranged by exertion, or by 
emotion, or by any other cause of reflex disturb- 
ance of the innervation. Hence to precordial 
anxiety we have superadded at least occasional 
irregularity of the heart's action in relation to 
rate, force, and rhythm. 

The heart beats because its muscular fibre is 
incompletely differentiated, and still 

^To'D&TfhQ'yhtS of 

the heart pri- retains the power of spontaneous 
mordiai in movement possessed by all primordial 
protoplasm.^ The heart's energy re- 
sides in its muscular fibre, and its quality depends 
upon the perfection of the cardiac metabolism. 

1 Balfour, op. cit., p. 31. 

2 Foster's Text-book o/ Physiology, 6th edition, 1888, p. 288 
et antea. 


The nervous system neither initiates nor main- 
tains the rhythmic movements of the 

heart, but it controls and regulates -^»^««™'^<'/ 

° the nervous 

them, and through it these movements system on the 

may be variously modified and even cardiac moue- 

■^ ■' ments. 


The agency by which the cardiac movements 
are controlled consists of a network of nervous 
filaments covering the surface of the heart, partic- 
ularly at its base. On the one side, this network 
is connected with various nervous ganglia, scat- 
tered throughout the substance of the heart, par- 
ticularly at the junction of the sinus venosus with 
the auricle, and in the auriculo-ventricular sulcus. 
On the other side this network unites into three 
distinct nervous cords, each of which plays a 
special part in regulating the movements of the 
heart. One of these cords (S", Fig. 1) passes 
through the first dorsal and the last cervical gang- 
lion into the sympathetic nerve, and through it 
there pass to the heart those impulses which in- 
crease the rate of its pulsations and augment their 
force.^ Acceleration and augmentation of the pul- 
sations are not, however, necessarily coincident.^ 

1 Untersuchungen ueber die Innervation des Serzens, von 
Albert v. Bezold, Leipzig, 1863, erste Abtheilung, S. 162. 

2 " Sometimes the one result, and sometimes the other being 
the more prominent." — Foster, op. cit., p. 294. Vide also Koy 
and Adami, Transactions of the Boyal Society, Vol. 183, p. 240. 



At times we have a rapid heart-beat with a 
quick, large, and full pulse, but at other times 
the heart-beat is rapid while the pulse remains 
small (vide Tremor cordis and Tachycardia, posiea). 
Further, it is through this nerve that the cardiac 
metabolism is effected, and its energy set free — 
it is the Katabolic nerve of the heart.^ 

The other two nervous cords which pass from 
the cardiac plexus (Q- and F, Fig. 1), both enter 

„, . and ascend to the brain along with 

The nerves of o 

the heart and the vagus nerve (E, Fig. 1), but each 
eir ac ions. ^^^^ -j.^ ggpa^^^^g origin and function. 

The superior cardiac nerve (F, Fig. 1) is an affer- 
ent nerve, and con- 
veys from the heart 
a controlling influ- 
ence to the vaso- 
motor centre in the 
medulla oblongata 
that regulates the 
movements of the 
arterioles, so that 
when a heart is la- 
bouring against a 
blood pressure too 
high for its powers, 

an impulse from the heart to this centre inhibits 
1 Gaskell, Journal of Physiology, Vol. vii., pp. 41 and 46. 

Fig. 1. 


the constrictor influences and tempers down the 
blood pressure to suit the cardiac strength.^ It is 
often called the Depressor Nerve of the heart. 

The inferior cardiac nerve (G^, Fig. 1), though 
it leaves the chest in the vagus bundle and is 
always referred to as a branch of the vagus nerve 
and its action as vagus action, is really more 
closely connected with the spinal accessory than 
with the vagus proper, and has a distinct root of 
its own. Von Bezold believed that this nerve was 
in constant action and thus supplies the natural 
tonicity to the heart.^ In the present day this 
tonicity seems rather to be regarded as the prop- 
erty of the cardiac muscular fibre and to depend 
upon the perfection of its metabolism. The action 
of the vagus is Anabolic; it inhibits the action of 
the augmentor or katabolic nerve, it slows and 
reduces the force of the auricular action, and may 
even wholly arrest it for hours. On the ventricles 
the vagus has not so powerful an effect; strong 
stimulation of the vagus may indeed arrest the 
action of the ventricles, but never for a period 
long enough to endanger life. When the vagus 
excitation reaches a certain degree (varying in 
different animals), the ventricles begin to beat 
independently of the sinus and the auricles, and 
this idio-ventricular action, at first slow and irreg- 
1 Poster, op. cit., p. 351, = Qp. ci«., S. 84. 


ular, gradually becomes fairly rapid and almost 
completely regular in its rhythm. The interfer- 
ence of the sinus and ventricular rhythms with 
_, , each other is the usual cause of irregf- 

77ie cause of & 

cardiac irreg- ularity of the heart's action, though 

u anty. irregularity may also be brought about 

by the auricles not responding to all the impulses 
which reach them from the sinus.^ Irregularity 
of action diminishes efficiency of the heart with- 
out reducing its expenditure of energy. This 
Dan erof Unfavourable effect is of little conse- 
cardiac irreg- quence if the intermissions are infre- 
u an y. quent, and the heart has a good 

margin of reserve force, but when the irregularity 
is great, or the heart feeble, diseased, or otherwise 
handicapped, it may form a very serious element 
of danger.^ In no class of cases is this danger 
^^ more likely to be serious than in cases 

Why most 

serious in of senile heart, because in these all 

cases of senile ^}^g elements of danger act in com- 

heart. . ° 

bination towards one result — dilata- 
tion of the ventricles, more especially of the left 
ventricle. The elements of danger in such cases 
are : first, the normal, and still more any abnormal, 
increase in the aortic blood pressure ; and, second, 
any abnormal diminution of the force of the 

1 Eoy and Adami, op. cit., pp. 293, 294, etc. 

2 Op. cit., p. 284. 


ventricular contractions from malnutrition, or 
otherwise. Each of these conditions prevents the 
ventricle from emptying itself, and increases the 
amount of residual blood in the heart, and then 
there comes into action the law that " the strain 
upon the walls of a sphere or spheroid increases 
with its circumference, and, therefore, the resist- 
ance to contraction of the heart wall is increased 
whenever it becomes dilated." ^ 

Vagus action slows the heart generally, lessens 
the excitability of the ventricles, and even when 
weak may reduce the output from them by as 
much as thirty per cent,^ thus causing residual 
accumulation and all the evils that flow from it. 
But inhibitory influences may pass to the cardio- 
inhibitory centre from every quarter, and we can 
thus understand how mental worries or even phy- 
sical derangements may, by a long continuance of 
petty inhibitions, seriously affect the cardiac func- 
tion, especially when these inhibitions occur at a 
period of life when normal alterations in structure 
tend to accentuate their evil influence. 

Irregularity or intermission should, therefore, 
never be looked upon as unimportant; as a drop 
hollows a stone non vi, sed scepe cadendo, so even a 
simple intermission may ultimately lead to cardiac 

1 Roy and Adami, op. cU., p. 213. 

2 Op. cit., p. 217. 


dilatation and the shortening of life. I well 

remember an old gentleman who for 

niustrative ^^ complained of what he called an 
case. ° ^ 

occasional "dunt" in his chest. This 

"dunt," — throb, — which was his only complaint, 
was nothing but the augmentor impulse following 
an inhibition. When I first saw him his heart was 
considerably dilated, and had been so for some 
time, as I learned from his medical attendant. 
But the old gentleman was quite distinct in his 
statement that many years previously, when seen 
by a distinguished consultant in the west of Scot- 
land, the doctor had told him that his heart pre- 
sented no sign of disease, but only of nervous 
derangement. As his complaint had been all 
along the same, I have no doubt that the inter- 
missions existed then, but that they had not as 
yet produced that dilatation which subsequently 
resulted. There was a strong suspicion that this 
patient indulged in some narcotic, but this was 
never brought clearly home to him, and he never 
confessed. He was somewhat relieved by treat- 
ment, but there was no marked improvement, and 
he was found dead in bed not long subsequently, 
no other symptom having developed. Simple in- 
termission was in this case the earliest and the most 
persistent symptom, and it must have had a most 
important effect upon the course of the disease. 


Intermission is a reflex inhibition of the heart 
through the vagus, of little conse- 
quence in youth, because the heart ^""S""- "/ «"- 

. termissions. 

has then a wide margin of reserve ; 
but of serious import after middle life, because 
all the conditions then present accentuate the 
tendency of persistent intermissions to induce 
dilatation of the heart. 

The inhibitory cause may be of any character 
and may come from any quarter; it 

,"■,.. . Xnhibitions 

may be physical or emotional, a dis- maybephysi- 
eased organ, a depraved secretion, or caioremo- 
a mental shock. A violent emotion — 
more especially, strange to say, if it be a joyous 
one — may fatally inhibit the heart's action ; a less 
violent but more persistent inhibition lessens the 
ventricular output,, increases the residual accumu- 
lation, and ends by dilating the heart; and if the 
exciting cause act with intensity, and the heart is 
already enfeebled, the dilatation may be rapid and 

The shock of a railway accident has been known 

to inhibit even a strong heart, and 

In a strong 
cause it to intermit ; but this is of jieart the effect 

little consequence in a young heart of even a 

. powerful inhi- 

with a good margin of reserve, as the bmon uiti- 
effect ultimately dies away. I have ™«*«'2/ <^»«« 
known the intermissions from this 


cause to drop within six months from one in 
every two beats to one in every twenty, and I 
have no doubt that they ultimately ceased alto- 

On the other hand, I have known the shock of 
a bv no means serious railway accident 

Even a tnflmg •' _ 

inhibition SO to break down a commencing senile 
may prove j^^^^^ ^^ ^^ ^^^^ within a year an 

rapidly Jatal _ •' 

to a weak infirm and dropsical invalid of an ac- 
heart. ^-^^ business man, and to kill within 

eighteen months a man who up to the time of the 
accident had scarcely been known to ail. Yet my 
„. . , own experience enables me to say with 

Time required -^ •' 

to develop di- considerable certainty that we may 
latationreek- ^^^T^^^ ^^^ twelve to thirteen years 

oning from •' 

the earliest as the time required for the develop- 
symptom. ment of serious dilatation in a middle- 
aged man leading a life of ordinary activity, but 
without hard work, and taking no special care, but 
also having no special worries, reckoning from the 
time the patient was first led to consult a physician 
on account of cardiac symptoms which were then 
regarded as unimportant. The time mentioned is, 
however, merely approximate, and though based 
upon observation, it is liable to many modifications 
the sources of which are obvious. 

I have spoken of a railway accident as a probable 
cause of cardiac inhibition, because in these days 


such an accident is one of the most common causes 
of serious shock ; but other forms of accident may 
be equally injurious, the result depending much 
more — in regard to cardiac disturbance — upon 
the violence of the attendant emotion than upon 
that of the physical shock. Thus Richardson nar- 
rates a case of shipwreck in which the fear of 
instant death from drowning caused the heart of 
a middle-aged man, in perfect health and spirits, 
suddenly to stop. He was rescued from his sink- 
ing ship and put on board another vessel, and 
when he had regained sufficient composure he 
found that his heart intermitted four or five times 
a minute. At first these intermissions were so 
disturbing as to prevent sleep; by and by they 
died away to two in a minute, and the patient was 
no longer cognizant of them unless he felt his 
pulse.i I have no doubt they ultimately ceased 
entirely, but this is not recorded. Richardson also 
tells us of another case in which wear- 

. . Intensity of 

ing anxiety of purely mental ongin emotion an 
developed persistent intermittency, ^"'■po^f^* 
followed by death from the silent but 
sleepless suffering produced,^ cardiac dilatation 
having doubtless an important influence on the 
fatal issue. 

1 Transactions of the St. Andrews Medical Graduates'' Asso- 
ciation, 1870, p. 238. 2 Op. cit., p. 239. 


We are all well acquainted with the intermis- 
sions due to the gastric irritation arising from 
flatulence, undigested food, or other disturbance, 
which are more prone to affect those with long, 
narrow chests than those with roomier paunches. 
We know also those intermissions due to the 
abuse of alcohol, tobacco, or other similar poisons. 
Such reflex or direct inhibitions are fortunately 
more easily remedied than many, but they are no 
less injurious to a senile heart, and they require 
to be carefully attended to and their recurrence 

The following sphygmogram (Fig. 2) was taken 
from the radial artery of a man whose feeble and 

Fia. 2. 

irregular pulse was the cause of considerable anxi- 
ety to himself as well as to his medical attendant, 
especially as there was no very evident reason to 
account for it. I found this patient to be a man 
of regular and unimpeachable habits, but that his 
health was considerably below par, apparently 
from confinement during office hours to a badly 
ventilated apartment in which a great deal of gas 
was burned. He was a valuable servant, and his 


employers were quite inclined to do their best for 
him ; so I told him to get his office properly ven- 
tilated, giving him at the same time a tonic 
mixture. The result was most satisfactory — 
within a month his health was quite re-established 
and his heart steadied ; he has kept well ever 
since, and conducts successfully the business of 
a large and important company. 

Here we had a young man (set. 36), organically 
quite sound, yet his life made useless and miser- 
able by a heart feeble, intermitting, and irregular, 
because the blood in its coronaries was impover- 
ished and depraved — a very good example of the 
apparent effect of the quality of the blood passing 
through the coronary arteries in governing the 

Chlorosis and Ansemia, especially that form of 
it — Hydrifimia — where the blood is plentiful 
enough but of poor quality, are very common 
causes of this form of irregularity. At rest such 
patients have feeble but regular pulses, but the 
slightest exertion produces one of two things — 
either a rapid and forcible heart-beat, or marked 
irregularity of the heart's action. To maintain 
the perfection of the muscular metabolism, imper- 
fectly oxygenated or otherwise impoverished blood 
has to be sent through the heart and other muscles 
1 Foster, op. cit., 1891, p. 344. 


much oftener per minute than healthy blood ; the 

augmentor nerve is therefore called into action, and 

the heart-beat becomes rapid and forcible. Should 

the heart be fairly well nourished, the blood not 

much below the average in quality, and the exertion 

of but short duration, this is all that happens : the 

rapid and forcible heart-beat quiets down when 

the need for it ceases, and the heart is none the 

worse for its effort. But when the heart is not 

so well nourished, the blood more depraved, or the 

exertion more sustained, the katabolic action of 

the augmentor nerve becomes dangerous to the 

integrity of the organ as well as to that of the 

organism, and the anabolic action of 
How vagus -mi. i mi 

interference the vagus IS called into play. ihe 
causes irreg- suffering heart sends a message to the 

vZarity. . , ., . , , - 

inhibitory centre, and the reply comes 

through the vagus as an inhibition which weakens 

the force of the auricular contractions, lessens the 

strength of the rhythmic excitation which reaches 

the ventricle from above, and at the same time 

diminishes the excitability of the ventricle itself. 

If the need of the heart be urgent, the inhibi- 
tion is strong, any stimulus reaching the ventricle 
from the auricle is but feeble, and, consequently, 
the ventricle sets up its own independent rhyth- 
mic action.^ The auricular rhythm and the inde- 

1 Vide antea, p. 40, and Boy and Adami, op. cit., p. 293, etc. 



pendent ventricular 
rhythm are each 
quite regular in 
themselves, but 
when they affect 
the ventricle at the 
same time, they in- 
terfere with each 
other and set up 
arhythmic irregu- 
larity.i The follow- 
ing sphygmograms 
are examples of this 
irregularity as oc- 
curring in feeble 
and dilated hearts. 

The one (Fig. 3) 
is from the radial 
artery of a digni- 
tary of a southern university, who 
died within a year from the time 
this was taken; the other (Fig. 4) 
is from the radial of a man who 
still survives and is well. 

When the heart is weak and 
dilated, or the blood much impov- 
erished, the most trifling exertion 
1 Roy and Adami, op. cit., p. 283. 

Fia. 3. 

Fig. 4. 


may call for anabolic action and give rise to 
arhythmic irregularity. But when heart and blood 
are only slightly below par, the violent exertion 
of a foot-ball match may be needed to induce 
irregularity, and under the restorative influence of 
rest this speedily dies away. 

Very important information as to the condition 
of the myocardium, and the state of the blood, is 
thus to be obtained from the greater or less readi- 
ness with which irregularity is evoked. The im- 
portance of this in the prognosis of a weak heart 
need scarcely be pointed out, and the value of a 
due recognition of the cause of irregularity in 
relation to the treatment of such a heart must be 
obvious to all. 

Irregularity as to force is a common accompani- 
ment of arhythmic irregularity, because every now 
and then the impulse from the auricle coincides 
with the ventricular systole, and there is an unusu- 
ally full beat, readily recognized by 

Cause of ir- •' ' ^ ^ •' 

regularity in the linger on the pulse, and just as 
the force of easily seen on the sphygmogram. This 
marked irregularity of the pulse-force 
constitutes a very distinctive difference between 
the irregularity of cardiac dilatation and that 
which so frequently accompanies mitral stenosis. 
In the former case a certain number of the radial 
pulsations are full and large, while in the latter. 


though the pulses do vary in force, there are none 
that can be called full or large. 

Irregularity in rate, though not peculiar to the 
senile heart, is yet, in some of its most remark- 
able varieties, most commonly found associated 
with it. 

These irregularities in the pulse-rate are inter- 
esting and important enough to re- ' 

quire a separate chapter to them- ^'="^«*»«« »» 
^ r r the pulse-rate. 

selves. I shall only mention them 
at present. 

Tremor cordis is a most remarkable phenomenon 
even to those well acquainted with it; and it is 
scarcely possible to conceive anything more alarm- 
ing than a first attack of what Sir Walter Scott 
called the morbus eruditorum, but which, alas ! is 
not nowadays confined to the erudite any more 
than Podagra is to the great and noble, with 
whom Sydenham flattered himself he had a com- 
munity of suffering, and there is no one who 
suffers from this tremor who is not ready to ex- 
claim with Sir Walter : " What a detestable feel- 
ing this fluttering of the heart is ! " ^ 

Tachycardia is a new name for an old complaint 
which, with its converse. Bradycardia, requires 
full detail to make it either interesting or under- 

1 Vide The Journal of Sir Walter Scott, Vol. i., p. 153. 
Douglas, Edinburgh, 1890. 


standable. None of these irregularities in the 
pulse-rate are strictly limited to the latter half of 
life, but they are most common and most distress- 
ing then, and it is thus convenient, if not strictly 
accurate, to treat them as affections of the senile 

The senile heart as I have described it is essen- 
tially a heart that has been overstrained through 
inability to do its work, while in many cases, as 
just pointed out, this overstrain or dilatation is 
precipitated by nerve interferences. The degree 
to which the cardiac cavities have already yielded 
we learn mainly from palpation and auscultation. 
In the hands of an expert careful percussion is 
^ , , . , , capable of yielding very trustworthy 
ing cardiac results in determining even a trifling 
dilatation. increase of the heart's dulness, but this 
is difficult even in a male chest, and in a female 
one it is still more so. On the other hand, the re- 
sults of palpation are easily obtained and readily 
comprehended ; for example, when an individual 
over middle life has his arteries atherosed, an 
accentuated aortic second, a firm, tense pulse, or 
a sphygmogram indicative of high intra-arterial 
blood pressure, with his apex apparently beating 
in the normal position, palpation at once reveals 
whether this apparent apex-beat is really the out- 
ward thrust of the point of the left ventricle, or 


merely the edge of the right ventricle. For the 
true apex of a normal heart is the strongest point 
of pulsation in the cardiac area, whereas the apex 
in a dilated heart is felt to be a mere extension 
from the strongest point of pulsation lying beneath 
the lower end of the sternum. At even an earlier 
stage, long before the right ventricle has become 
so mai'kedly dilated as to produce a pulsation be- 
neath the sternum marked enough to be detected 
by palpation, the ear through the stethoscope can 
readily distinguish the abnormal strength of the 
right ventricular impulse. 

The pulmonary circulation being a closed cir- 
cuit, whatever hinders the onward flow of the 
blood through the left heart, exerts an equally 
obstructive influence on the flow through the 
right ventricle ; this consequently dilates, and, 
as the right ventricle lies between the sternum 
and the left ventricle, a very slight dilatation 
suffices to push the left apex from the chest-wall 
into the cavity of the thorax, its place being taken 
by the right apex. 

As the heart dilates, the apex-beat extends 
gradually outwards to the left till it reaches 
the nipple line, or even beyond it, keeping in 
the fifth interspace, but beating three or more 
inches from mid-sternum instead of only two and 
a half. 


During the gradual dilatation of the heart its 

normal sounds undergo a progressive 

C'tens-es alteration that ends in a loud, systolic 

which the _ •' 

heart's sounds murmur in all the cardiac areas. The 

undergo dv^- gg ^^ is aS f olloWS : — 

tng dilatation. ^ 

In the very earliest stage, when the 
sole symptoms are precordial anxiety, a feeble 
impulse, and an accentuated second sound (^vide 
p. 35), the first sound is always more or less 
altered. It may be prolonged, blunt, feeble, or 
impure ; now and then we have it loud, clear, and 
booming ; over the right apex, when the heart is 
dilated, the first sound is always more distinct 
than over the left apex, except the booming sound, 
which is a left-side phenomenon, and best heard 
just below and to the left of the nipple. Distinct- 
ness of sound is probably as much due to the reso- 
nating qualities (thinness and flexibility) of the 
chest-wall as to any particular state of the ven- 
tricle ; the booming quality conveys to the mind 
the idea of tension, and seems to indicate consider- 
able dilatation of the ventricular cavity.^ Often 
accompanying one or other of these alterations of 
the first sound, and certainly speedily following it 

1 For various views as to the state of the first sound in dilata- 
tion of the heart, vide Hope, Diseases of the Heart, 3d ed., p. 68 
et seq.; Walshe, Diseases of the Heart, 3d ed., p. 315 ; Stolces, 
Diseases of the Heart, etc., p. 217. Also Gairdner, Ed. Medical 
Journal, July, 1856, p. 55, 


in orderly sequence, the educated ear has no diffi- 
culty in detecting a systolic murmur in the auric- 
ular area, in appropriate cases. This auricular 
murmur is a murmur audible between the second 
and third ribs to the left of the sternum, just out- 
side the pulmonary area. The pulmonary arterj'-, 
as we know, comes to the front between the second 
and third ribs on the left side, one half of its 
breadth lying beneath the sternum, and the other in 
the interspace. If we put a finger-tip 

, , . 1 ■ , 1 , , 1 Position and 

in this second interspace, close to the ^^^gg gf tj^^ 
edge of the sternum, we cover the pul- auricular 
monary artery, and just outside of the 
finger-tip the left auricular appendix in most hearts 
reaches the chest-wall, and if large and dilated, 
passes to the front of the ventricle at the root of 
the pulmonary artery. The appendix auriculi is 
not always long enough to reach the 

~ 1-1 ii • Why the 

surface, and m such a case the auric- auricular 
ular murmur is naturally not to be murmur is not 
heard; but in all cases in which this ^^^"1* 
murmur is audible it may be accepted 
as an early and infallible sign of mitral regurgi- 
tation,^ and consequently of ventricular dilatation 
in cases such as those now referred to. Failing 
this auricular murmur, and often accompanying it, 

1 Naunyn, Berliner kliniache Wochenschrift, 1868, No. 17, 
S. 189 ; and Balfour, op. cit., p. 171. 


we have as an early sign of ventricular dilatation, 

an occasional systolic whiff over the 

symlicwUff apex. For a time this whiff is tran- 

an early sign sitory, more audible at one time than 
of dilatation. , , , , , . , • i i 

at another, and sometimes entirely ab- 
sent, replaced by a more or less altered first sound. 
These variations depend on the state of the circu- 
lation, the murmur being always most distinct after 
exertion and not so audible — often entirely absent 
— when the patient has been resting. But a systolic 
How this murmur, due to progressive dilatation 

systolic mur- of the left ventricle, does not long 
mm sprea s. j.gma,in trifling or evanescent. Ere- 
long it is to be found whenever listened for ; it is 
speedily followed by a systolic tricuspid murmur, 
and then we have a systolic murmur in all the 
cardiac areas. In the aortic and pulmonary areas 
this murmur is partly due to propagation from the 
mitral and tricuspid openings, and is partly pro- 
duced there, as an early phenomenon in the aorta, 
and a late one in the pulmonary artery, by the 
passage of the blood through the comparatively 
narrow arterial openings into the dilated arteries 
beyond. By the time the mitral and tricuspid 
murmurs have developed there is no difficulty in 
determining from its enlarged percussion area, 
and from its forcible impulse, that the heart has 
become, not only dilated, but also hypertrophied. 


The accentuated aortic second is always an indi- 
cation of a dilatable aorta, but by itself it is not 
a sign that the aorta is actually dilated. 
After death, in such cases, the aortic accentuated 

walls are always found to be inelas- aortic second 
,.,.,.»., , , indicates. 

tic ; during lite the aorta expands 

helplessly before the advancing blood-wave, which 
for want of its normal elasticity it fails to pass 
completely onwards. The excess of blood in the 
inelastic ascending aorta falls back on the sigmoid 
valves and closes them, with unusual force, by the 
mere virtue of its abnormal weight (or momen- 

At first, and for a time, the aortic second is 
merely accentuated in virtue of possessing a louder 
and more distinct sound than usual : ^, 

The meaning 

by and by there is superadded a boom- of a hooming 
ing quality, which indicates closure by ^^''°"-^- 
a heavier blood-column, throwing a greater tension 
on the aortic valve. As this tension gradually 
increases the segments of the valve tend to get 
separated, and to permit of regurgitation between 
them into the ventricle. In this condition any- 
thing which diminishes the size or weight of the 
aortic blood-column, or that increases 
the tone, or diminishes the extensi- "'" eaonc 

I. v/ >,>^ v/, regurgitation. 

bility of the aortic walls, diminishes 

the regurgitant force of the blood, and thus an 


aortic regurgitation of this character is curable, 
and is occasionally cured. 

Often, however, the aortic walls are not merely 
inelastic and dilatable, but rigid, atheromatous, 
and the lumen dilated. In these cases 
^syZiilmur- the blood-wave does not merely dilate 
raur in aortic the passive walls of an inelastic aorta, 
dilatation. ,, ,, i,i t j_- ^ n 

but passes through the relatively small 

aortic opening into the dilated artery beyond, and 
in so doing forms fluid veins which give rise to a 
systolic aortic murmur; an indication not of mere 
dilatability of the aortic walls, but of actual dila- 
tation of the aortic lumen. 

A merely accentuated aortic second, then, only 
indicates with certainty an inelastic and dilatable 
condition of the aortic walls; but an accentuated 
aortic second, coupled with a systolic aortic mur- 
mur, indicates an actual dilatation of the aortic 
lumen, and this may be confirmed by percussing 
the aorta and mapping out its dulness. The 
history of the case, and the fact that diseased 
valves, capable of themselves — by obstructing the 
arterial exit — of originating a systoUe murmur, 
are, from sheer inflexibility, incapable of accentu- 
ating the second sound, help to confirm the diag- 
nosis. This actually dilated state of the aorta is, 
much more often than a merely dilatable one, fol- 
lowed by separation of the segments of the aortic 


valve, and by regurgitation into the ventricle. 
Hence it has long been known that in many cases 
— all, indeed, of this character — a systolic aortic 
murmur precedes for an indefinite period the de- 
velopment of regurgitation.! At first we have 
only an occasional diastolic whiff accompanying 
the booming second, and generally to be earliest 
heard at the sternal end of the fourth rib on the 
left side. As in the case of the systolic whiff 
in the mitral area, this diastolic aortic 
whiff gradually becomes permanent, -P''«c<"'*«' 

o •' jr ' anxiety may 

and gets louder and more prolonged terminate in 
as the regurgitation becomes freer, ""^""^ """ 

° o ' num. 

until at last the case which com- 
menced as one of precordial anxiety with an 
accentuated second, a feeble impulse, and an im- 
pure first sound, terminates as a cor bovinum with 
a heaving impulse, and a double murmur more or 
less audible in all the cardiac areas. 

Erelong this condition is followed by renal con- 
gestion, albuminuria, and dropsy. Fortunately, all 
these troubles are preventable, and 

early attention to the beginnings of ^^t this may 

•' o o oe averted. 

evil may not only avert these un- 
toward results, but promote a green and healthy 
old age. 

No arguments are required in the present day 

1 Stokes, op. cit. , p. 227. 


to prove that stress of work, from increase of the 
intra-arterial blood pressure, is sufficient to induce 
dilatation of the heart. It is acknowledged by 
pathologists,^ and has been experimentally induced 
by physiologists.^ 

Ventricular dilatation is speedily followed by 
regurgitation through the auriculo-ventricular 
opening, and this is now universally acknowl- 
edged to be accompanied by an impure first sound, 
which speedily develops into an unmistakable sys- 
tolic murmur.^ Various explanations 
Howregurgi. have been given of this valvular in- 
brought about, competency without valvular lesion. 

re sac- -pj^^ explanation which seems best to 
count of It. '^ 

agree with the facts is that given by 
Ludolph Krehl. This observer points out, what 
has indeed been long known, that in the normal 
heart the valves are floated into apposition, and 
the auriculo-ventricular opening closed previous 
to the commencement of the ventricular systole ; * 

1 Ziegler's Pathological Anatomy, by Macalister, London, 
1884, Part ii., p. 49. 

2 Eoy and Adami, British Medical Journal, December, 1888, 
p. 1321, etc., and Transactions of Bmjal Society, loc. cit., pp. 
213 and 278, etc. 

8 The first recognition of this as a necessary complement of 
ventricular dilatation, and not a mere accidental complication, 
we owe to Dr. Gairdner. Vide "The Evolution of Cardiac 
Diagnosis," JEd. Medical Journal, June, 1887, p. 1080. 

* Vide Pettigrew, "On the Relations, Structure, and Func- 


were it otherwise, a manometer within the auricle 
would infallibly indicate regurgitation at the 
moment of systole. When, however, the ventricle 
is dilated, there is regurgitation — so-called rela- 
tive insufficiency is established. Not because the 
auriculo-ventricular opening is dilated, — that is 
a later occurrence, — not because the segments of 
the valve are unable to close the opening, — one 
alone of these segments is almost sufficient for this 
purpose, — but because the insertions of the chordce 
tendinecB into the papillary muscle, owing to the 
ventricular dilatation, are set so wide apart and so 
far from the centre of the ventricle that the trifling 
pressure of the auricular blood is unable to bring 
the valve-segments into apposition.^ Under these 
circumstances whenever the ventricular systole 
commences, regurgitation occurs ; at one time to 
but a limited amount, at another to a greater. 

When we listen over the apex of a dilated heart, 
we hear in some cases only an impure first sound, 
in others a systolic whiff precedes a quite closed 
first sound, and in still others a murmur begins 
with the beginning and continues throughout the 
whole of the systole. 

tion of the Valves of the Vascular System," Transactions of 
the Boyal Society of Edinburgh, 1864, p. 799 ; and Physiology 
of the Circulation, London, 1874, p. 284. 

^ Vide Archiv fur Anatomie und Physiologie, Leipzig, 1889, 
S. 291. 


This agrees exactly with Krehl's account ; when 
the ventricular systole begins, the valve-segments 
are not in apposition as they ought to be ; but as 
the systole progresses all the conditions conduce 
to the perfect closure of the valve, when the dila- 
tation is slight. It is quite a different story when 
the dilatation is considerable, or the valves dis- 

There are two other symptoms which are of 
serious import in advanced life, though neither 
of them is limited to that period. 

As an accompaniment of imperfect circulation, 
pulmonary congestion, or defective hgemoglobin, 
Breathlessness is the commonest symptom of car- 
diac failure at every age ; it is never absent when 
any exertion is called for. But connected Avith 
the senile heart breathlessness assumes a different 
aspect — exertion is not needed to induce it; it 
may occur when the sufferer is at perfect rest, and 
it may even awake him from sleep. When it 
harasses the patient in this way, breathlessness 
gets the name of cardiac asthma, and is often an 
early symptom of cardiac failure. In 
Angina""*""'' *^^® Connection it is a true Angina, 
and much more entitled — etymologi- 
cally — to that appellation than the painful affec- 
tion that commonly bears it. These two forms of 
angina will be treated of together, later on. 



Palpitation is a common complaint of those 
who suffer, or who think they suffer, from disease 
of the heart. It is a term commonly applied to 
all forms of abnormal cardiac pulsations which 
make themselves unpleasantly sensible to the 
sufferer — to intermission as well as to irregular 
action. Therefore, although palpitation is not a 
symptom peculiar to the senile heart, 
— is, indeed, more apt to affect the „eare by the 
young than the aged, — it is yet well term"paipi- 

1 1 1 • 11- tation." 

to denne clearly what is meant by this 

term, so that it may be differentiated from other 

forms of heart hurry. 

The distinctive peculiarities of palpitation are 
a regular, rapid, and violent pulsation of the heart, 
which often shakes the whole chest and always 
makes itself unpleasantly sensible to the sufferer, 
accompanied by a violent throbbing of the aorta, 
carotids, and other large arteries, which does not 



extend to the smaller vessels, the radial pulse 
giving no indication — in its force, at least — of 
the violence of the heart's action. Palpitation 
comes on suddenly, and may last from a few min- 
utes to several hours ; it is very distressing and 
often alarming to the sufferer, but it is not usually 
attended by any danger. It seems to be caused 
by reflex inhibition of the vagus action, a reflex 
paralysis of the inhibitory centre which removes 
the restraining influence of the vagus, and allows 
the augmentors temporarily to run off with the 
heart. Palpitation occurs in weakly and anaemic 
individuals, and is produced by reflexes of emo- 
tional or gastric origin, never by exercise. The 
rapid, forcible augmentor action that follows exer- 
tion in a spansemic person (vide p. 47) simulates, 
indeed, palpitation closely ; but in such a case the 
radials beat fully and forcibly, the heart's action 
is not so violent and throbbing, and all the phe- 
nomena cease at once whenever the patient be- 
comes quiescent. 

Tremor cordis is a very remarkable form of 
cardiac irregularity. It is the very opposite of 
palpitation. Emotion has nothing to do with its 
causation, and the heart, instead of throbbing as 
if it would burst the chest-wall, trembles like 
an aspen leaf. It occasionally occurs in youth; 
it is common enough in advanced life ; it is most 


alarming not only from its peculiar character, but 
also from the sudden way in which it seizes its 
victims. We talk of a bolt from the blue as the 
most startling thing that could happen, but it 
could not be more startling than that a heart 
beating quietly and steadily should suddenly be 
seized with a rapid, tremulous fluttering, most 
alarming to the victim not only from the unusual 
character of the sensation, but also and especially 
because of the organ affected ; for life truly seems 
slipping away when the heart itself trembles. This 
affection was well known to Senac ^ 

Tremor cor- 

and the early physicians, who seem to dis. Whatu 
have taken rather a serious view of it. *'' 
These attacks occur without warning, and pass off 
in a few seconds, apparently without detriment 
to the patient. They are generally spoken of as 
"a fluttering of the heart," and such indeed they 
are. The sensation is precisely as if the gouty 
twittering of the muscles spoken of by Begbie ^ 
had affected the cardiac muscle. The pulse does 
not die away ; it does not taper off like a pulsus 
myurus, but it suddenly drops from the ordinary 
full pulse of health to a mere tremulous thread. 
The attacks vary from three or four sharp, short, 
and apparently incomplete systoles, rapidly suc- 

1 Contributions to Practical Medicine, by James Begbie, 
M.D., Edmburgh, A. & C. Black, 1862, p. 6. 


ceeding one another, and running off without warn- 
ing from a heart beating regularly and steadily, 
up to a whole series of rapid, short, and incomplete 
systoles, which may last for several seconds, con- 
vey a tremulous sensation to the hand laid over 
the cardiac region, and are accompanied by a small, 
fluttering, and often scarcely perceptible, radial 
pulse. This tremor ends suddenly like an inter- 
mission, with an unusually forcible beat, and from 
a similar cause. During all those imperfect sys- 
toles, the ventricle has been getting gradually 
overfilled, the augmentor nerve is called into play, 
the ventricle forcibly expels its contents, which 
escape freely, and gradually distend arteries which 
have had time to get unusually empty. The heart 
then settles into its ordinary rhythm. 

Tremor cordis is not confined to the senile heart. 
It may happen at any age. It may attack a heart 
apparently healthy, or it may accompany any form 
of heart affection ; but it is most common after 
middle life, and in hearts which are feeble and 
dilatable. Sir Walter Scott called it the morbus 
eruditorum, and tells us that in his youth it used 
to throw him into "an involuntary passion of 
causeless tears." ^ I myself am well acquainted 

1 "I know," he says, " it is nothing organic, and that it is 
entirely nervous, but the sickening effects of it are dispiriting 
to a degree." — Op. cit, p. 153. 


with a man now getting on for seventy, who, 
at nineteen, was suddenly and without warning 
seized with a sharp attack of tremor 
cordis. This happened iust previous C'«««<'/ti^emor 

'■ '■ _ "" ^ cordis. 

to an attack of relapsing fever, and, 
up to quite recent times, it remained an only one. 
Of late, these seizures have been more frequent. 
His heart has always been irritable, but he has a 
long, narrow chest, and those having this confor- 
mation have almost invariably irritable hearts. 
He has always enjoyed good health, but may be 
said to be hereditarily disposed to heart affection 
on the mother's side. On the father's side, the 
deaths have been for generations, in the direct line, 
all over eighty, usually from cerebral apoplexy. 
Rheumatism is unknown on either side. Further, 
this patient tells me that occasionally 
he has been able to arrest this tremor ^"["'^/f?' «'- 

rest of the 

by a voluntary impulse through the heart's action. 
inhibitory centre, not absolutely, but f ™ *™"^"' 
markedly enough to his own sensation. 
Nor is this impossible. There is one medical man 
recorded by Fothergill as possessing the power of 
voluntarily arresting the heart's action, ^ and we 
are all acquainted with the remarkable case of 
Colonel Townsend, narrated by Dr. Cheyne ; ^ not 

1 Lancet, I., 1872, p. 498. 

2 The English Malady, by George Cheyne, M.D., London, 


to mention the Indian fakeers, who undoubtedly 
possess the power of arresting both pulsation and 
respiration, as we gather from those remarkable 
cases, narrated by Dr. Braid, where they submitted 
to be buried for so long as six weeks at a time, till 
their clothes were all mildewed and rotten.^ This 
power is now believed to be exercised by voluntary 
compression of the spinal accessory by the muscles 
of the neck, which transmits a powerful inhibition 
to the heart through the cardiac branch of the 
vagus with which the spinal accessory is so in- 
timately connected. 

Tremor cordis, rare in youth, common enough 
after middle life, is always spoken of as a flutter- 
ing of the heart, and can generally be associated 
with flatulence or some other gastric disturbance. 
Never, in all my experience, has any form of emo- 
tion had any share in its causation. Indeed, it is 
the sudden way in which, without a thought being 
directed towards it, an apparently healthy heart, 
beating quite regularly and steadily, begins to 
flutter within the chest that makes it so alarming 
to the sufferer. No feeling of faintness seems ever 
to be connected with this most uncomfortable sen- 
sation. It is a most singular phenomenon, and 
difficult to explain satisfactorily. Evidently the 

^ Observations on Trance, by James Braid, M.R.C.S. Ed., 
A. & C. Black, Edinburgh, 1851. 


vagus is reflexly inhibited, the heart uncontrolled 
goes off at a gallop, till the ventricle, which all the 
time has been gradually getting overfilled, sud- 
denly invokes augmentor aid, expels its contents 
with a bang, and at once settles down steadily 
under normal nervous control. This explanation 
certainly agrees with the facts. The shorter the 
period of tremor, the less forcible the impulse with 
which the heart returns to work. 

Tachycakdia, or heart hurry, is a symptom not 
confined to the senile heart nor to the latter half 
of life, but it is most dangerous to the aged, and 
in them it is always pathological. In infancy 
tachycardia is a physiological phenomenon, as the 
heart of the new-born babe beats at the rate of 130 
per minute, gradually dropping to 100 at three 
years of age. In pathological tachycardia, the 
heart-rate is said to reach 200 or even 300 per 
minute. I myself cannot distinguish with any 
certainty over 150 pulsations a minute. By the 
aid of the sphygmograph we may certainly count 
more, but I have never found them over 200. 
One great distinguishing peculiarity of patho- 
logical tachycardia is the little disturbance it gives 
the sufferer. With a heart beating more rapidly 
than that of an infant, he goes about his duties as 
unconscious as a babe of anything unusual. This 
is one great difference between tachycardia and 


palpitation, with which it is so apt to be con- 

During the first two years of life, the rapid 

action of the heart depends upon the low blood 

pressure, and concurs with it in pro- 

Normai j^^j-i ^he diffusion of the blood- 

tachycardia. o 

plasma and the rapid growth of the 

tissues. Infantile tachycardia is the necessary- 
result of the conditions under which the circula- 
tion is then carried on ; in its turn it is subservient 
to the building up of the frame, and it gradually 
ceases as the intra-arterial blood pressure rises and 
development takes the place of growth. At any 
later period of life tachycardia is an abnormal phe- 
nomenon, and indicates some interference with the 
physics of the circulation, or with those nervous 
connections by which its various interdependent 
relations are maintained and regulated. 

In a few cases tachycardia is found in women at 
the menstrual period, or during the puerperium; 
it is also occasionally observed in both young and 
old recovering from an illness, their hearts never 
quite falling to the normal rate, and by some all 
of these varieties of heart hurry have been looked 
on as physiological. But all such cases are excep- 
tional and essentially morbid in their causation, 
as are even those still rarer cases in which the 
rapid heart of infancy persists even to old age. 


I am acquainted with one instance of this — a lady, 

now a widow over seventy, who has „ . , 

■' ' Persistence 

had a large family, and whose pulse of infantile 
up to quite recent years was never un- <«<'''2'«'"-''»«- 
der 150 per minute ; now it is only seventy. This 
lady is of a highly neurotic temperament, but she 
has always enjoyed good health, and there never 
was any violent or distressing throbbing either in 
the region of the heart or at the root of the neck. 

In tachycardia the heart's action is rapid and 
feeble, and the sounds are empty, like the tic-tac 
of the foetal heart, while the radial pulse is quick, 
feeble, and sometimes almost imperceptible — a 
state of matters by no means devoid of danger, 
and one which may terminate suddenly either in 
Syncope or Asystole, and which differs toto coelo 
from other affections to which, so far as the heart- 
rate is concerned, the term tachycardia is equally 

How completely, for example, does the Syn- 
drome of such an affection differ g^„^,„„, „^ 
from that of so notable an instance exopthaimic 
of rapid heart as exopthaimic goitre. ^'"'™' 
And yet in Graves' disease there is often for 
months neither exopthalmos nor goitre — nothing 
but a rapid heart. 

There is always tachycardia so far as rate is 
concerned, the pulse beating 140 or more per 


minute ; but the heart's action is violent, and the 
whole arterial system throbs disagreeably. The 
heart sounds are clear and distinct, and some- 
times so loud that Graves, to whom we owe the 
earliest description of this disease, says in refer- 
ence to one of his cases, " I could distinctly hear 
the heart beating when my ear was distant at 
least four feet from the chest." ^ At times this 
violent perturbative palpitation of the heart and 
arteries exists alone ; at other times this is associ- 
ated with goitre only, or with exopthalmos only, 
or all these three symptonis may be present ; but 
always and in every case the violent throbbing of 
the heart and arteries is sufficient to distinguish it 
from mere tachycardia. 

Those who believe in an essential tachycardia 

TaoUycardia ^P^^^ "^ *^e ^^art hurry of febrile or 
always symp- exhausting diseases as a symptomatic 
tachycardia; and in like manner the 
rapid pulse, feeble impulse, and empty heart 
sounds, which so often accompany and herald the 
approach of death, may with more reason be termed 
the tachycardia morientium, inasmuch as it is some- 
times difficult to say whether the tachycardia is 
merely the herald or not also the cause of death. 

1 A System of Clinical Medicine, by Robert James Graves, 
M.D., Dublin, 1843, p. 674. This Lecture was first published 
in 1835. 


For, while holding that tachycardia is only a 
symptom, it must still be acknowledged there 
are many cases in which it is the only detectable 
symptom. Are these to be considered cases of 
true, essential tachycardia or not ? I feel certain 
that careful enquiry will in every such case dis- 
cover some previous heart strain sufficient to 
originate an endocarditis or a myocarditis, some 
coexisting chronic disease, some history of an 
overwhelming emotion, or the abuse of some car- 
diac poison, any one of which may be quite suffi- 
cient to account for the predominant symptom. 
I have seen many cases of tachycardia due to 
heart strain ; many of these got well without 
developing any further symptom. Whether these 
were cases of slight and evanescent endocarditis 
or of myocarditis no one could say. On the other 
hand, cases which throughout their whole course 
presented no other symptom have terminated in 
stenosis of the mitral opening, as revealed by all 
the ordinary and well-known signs, and have thus 
sufficiently plainly indicated their endocarditic 
origin. Never less than two years were required 
for the development of a presystolic murmur, reck-* 
oning from the first appearance of the tachycardia, 
and often much longer. 

But tachycardia is not only, as it were, a cause 
of mitral stenosis ; it is a very frequent accompani- 


meiit of that affection. Indeed, in a well-marked 

case of tachycardia, I would look first 
Tachycardia ... 

may te.rm.i- for the Signs of mitral stenosis, and 

nate in mitral fa,iling them, for the signs of a dilated 
stenosis. ■ 

heart with marked indications of arte- 
rial atheroma. In the one case the heart's action 
is apt to be not only quick, but also irregular; we 
have an accentuated first sound, and generally a 
well-marked pulmonary second, though sometimes 

from ansemia this is not so well marked 
And is often 
an accompani- as it ought to be ; thesc signs, coupled 

ment of that ^j[j;h the history of the case, enable us 

to differentiate it from similar rapid 

hearts, with, at all eyents, considerable proba- 

On the other hand, when the heart is slightly 
May be caused enlarged, dilated, and hypertrophied, 

by imperfect w^ith persistent tachycardia, there is 

metabolism of . . 

the myocar- Suspicion of interference with the cor- 

dmm. onary circulation, or of some condition 

of the blood inyolving imperfect metabolism of the 

In the latter half of life tachycardia is a symp- 
tom associated with yarious forms of degeneration, 
and if not from the first dependent upon cardiac 
disease, it is always associated with cardiac dilata- 
tion. From almost the first, even in those cases 
which seem strictly essential, there is increased 


precordial dulness, dependent on imperfect ventric- 
ular systole with residual accumulation, which is 
so essential a part of the affection, and which is 
increased and accentuated by all those obstacles 
to the onward flow of the blood which we know 
to form so integral a part of the senile changes in 
the circulatory system. Tachycardia is thus not 
only, in many cases, an important sign of senile 
cardiac degeneration, but is also in itself an addi- 
tional danger to the senile heart. 

In infancy and childhood tachycardia is normal 
and physiological ; in febrile diseases it is a never- 
failing symptom ; in anaemia and other 

. . Conditions in 

states 01 exhaustion, and in many wuch tachy- 

diseases of the heart and blood-vessels, ««'"''»'=' ™«2' 

be present. 
tachycardia is not an unusual symp- 
tom; while the other conditions with which this 
affection is found connected may be comprehended 
under two heads — intoxications and affections of 
the nervous system. 

The various intoxicants, or poisons, which give 
rise to tachycardia, comprise first of all — alcohol. 

And in speaking of alcohol as a cause of tachy- 
cardia, no reference is meant to the ordinary rise 
of pulse that follows the use, or still ^i^,j,„j^,^ 
more the temporary abuse, of alcohol, cause of tachy- 
but solely to those cases of persistent 
rapid heart action, empty heart sounds, and feeble 


pulse, which alone constitute the syndrome of 
tachycardia, and which are occasionally found in 
connection with chronic alcoholism. 

In such cases sudden death not infrequently 
occurs, and the heart is found dilated and fibro- 
fattily degenerated. In these cases the tachy- 
cardia is believed to depend upon a neuritis of the 
vagus, due to the abuse of alcohol. Such cases 
are always serious, and are probably much more 
common than is as yet recognized. In some of 
them, and these the least serious, the heart and 
pulse are irregular as well as rapid, and the brain 
unaffected ; in others the tachycardia either exists 
alone, or it may accompany delirium tremens, and 
it is then apt to be merged in what appears to be 
the more serious affection, while after all in the 
heart trouble the real danger lies, the nervous 
symptoms being of comparatively little conse- 
quence and quite appeasable by a twelve-hours 
sleep. As practitioners we are so apt to recognize 
a quick pulse as a usual accompaniment of the 
consumption of alcohol, and delirium tremens as 
a result that not uncommonly precedes the end, 
that we are apt to forget that the chronic abuse of 
alcohol originates a fibro-fatty degeneration of the 
myocardium, as well as a neuritis of the vagus, 
that the one impedes the cardiac function, and the 
other by paralyzing inhibition permits the heart 


to fly off in a hurry, impedes recovery, and duly 
recognized may be accepted as a measure of the 
danger present. 

Tea and coffee used in moderation increase at 
first both the force and frequency of the heart's 
action, and induce a pleasant excite- 
ment of the cerebral functions, but „J!fl°L^ *" 
the abuse of these stimulants pro- may be a 
duces in some actual intoxication, and tachycardia 
in others that lowering of the blood 
pressure and acceleration of the heart's action 
which occasionally leads to an attack of tachy- 
cardia, during which the pulse is in some irregular. 

Tobacco is, however, that poison most largely 

abused by man, and from that abuse we gain a 

large experience. Nicotine, the poison- 

n T • 1 n 1 r^ t Influence of 

ous alkaloid of tobacco, at first slightly tobacco in 

slows the heart, or it may arrest it i"''"'"c»»9' 

momentarily, causing intermission, or 

the inhibition may be strong enough to start the 
ventricle on its own independent rhythm, when 
irregularity soon follows (^vide antea, p. 40). 
When the dose is powerful enough to paralyze 
the vagus, the heart set free from its restraining 
influence starts off at a gallop, and we have an 
attack of paroxysmal tachycardia, with embryo- 
cardiac sounds, and increased precardiac dulness. 
The heart's action at times seems tumbling and 


irregulai-, but the pulse itself is small, feeble, and 

The following sphygmogram (Fig. 5) is an ex- 
ample of a hyperdicrotous, tachycardiac pulse of 

Fig. 5. 

low tension, beating perfectly regularly at the rate 
of 170 per minute, as reckoned by the sphygmo- 

This patient was suddenly seized with his tachy- 
cardia while playing a match at golf ; he thought 

of giving it up, but a bumper of 
Sc^Ldia. whiskey enabled him to win his match 

with what must have been a perfectly 
uncountable pulse, as even when at rest in bed 
this is never under 170 during an attack. This 
patient is now over sixty years of age, and during 
the last eight years he has had several similar 
seizures, all of them due to excessive smoking 
coupled with a good many nips of whiskey, the 
whiskey being never taken to excess. I have 
known his family for more than one generation, 
and not one of them has ever complained of the 
heart but himself, and he, indeed, resents his ail- 
ment rather than complains of it. 


A rapid heart -beat means, as Bonders first 
pointed out, a shortening of the systole,^ a small 
amount of blood expelled by each ventricular con- 
traction, hence shortening of the primary wave 
in the pulse-tracing and increased depth of the 
dicrotic notch, dicrotism of the pulse and pulse- 
tracing. When the pulse-rate is much increased, 
the pulse becomes hyperdicrotic ; the ordinary 
dicrotic notch is carried on to the ascending limb 
of the tracing, and seems to be anacrotic, as in the 
sphygmogram here given. In this case there was 
a small, feeble, perfectly regular, but very rapid 
pulse (170), no dicrotism to be detected by the 
finger, but hyperdicrotism very evident in the trac- 
ing. There was increased precordial dulness, and 
a feeble, wobbling heart-beat, evidently a condition 
in itself not devoid of danger at any age, and one 
which indicates most unmistakably the risk to 
which a senile heart is exposed by an attack of 
tachycardia. Every dicrotic pulse is not a rapid 
one, neither is every rapid pulse dicrotic. But the 
amount of danger present in any case of tachy- 
cardia may be to a large extent measured by the 
degree of dicrotism present in the pulse, as this 
indicates diminution in the amount of blood ex- 
pelled from the ventricle (contraction volume), 
increased residual accumulation, and tendency to 
1 Ne^rl. Archiv. voor Genees-en Naturk., Bd. ii., 1865, S. 184. 


death from failure of the heart — sudden or in- 
gravescent asystole. 

In sudden death from cardiac failure there is 

failure of the heart to contract, failure of the 

, , , heart to respond to the call of the 

Asystole may ^ 

be sudden or katabolic nerve — Asystole. At times, 
ingravesoent. ^^^^^^^^ the failure to contract is not 
sudden and complete, but occupies an appreciable 
period of time, from a few moments to a few days, 
or even longer, and it is then most appropriately 
termed Ingravescent asystole. 

In neither of these forms of asystole is there 
any feeling of f aintness — only a sensation of im- 
pending dissolution, and a gradual failure of both 
pulse and heart, the act of dying occupying but a 
few minutes, and the mind remaining clear to the 

When the asystole is of longer duration, the 
pulse is small, feeble, quick, and sometimes irreg- 
ular ; the heart's action is rapid, feeble, sometimes 
wobbly; the liver and spleen are congested, and 
if dying is prolonged, they may enlarge. There is 
oedema of both lungs, or oedema of one lung and 
effusion into the other pleura; there is often 
slight blood-spitting, from general pulmonary con- 
gestion or from local patches of pulmonary apo- 
plexy due to thromboses ; the oedema of the lung 
1 Balfour, op. cit., p. 306. 


is sometimes so great as to make the part affected 
seem solid, yet this solid cedema may disappear 
in a few hours, or it may shift its place when the 
position of the body is changed; there is slight 
cedema of the feet and ankles, with a slowly 
increasing soakage of all the tissues, a trace of 
albumen in the urine, which slowly increases, and 
a duskiness of the skin, which deepens as death 
approaches, and is most noticeable at the finger 
tips and nails. As a rule there is no recovery 
from this condition, though death may be linger- 
ing. This, however, depends of course upon the 
inducing cause ; in olden times, when aconite was 
looked upon as the equivalent of digitalis, I have 
seen hearts brought into a state of almost fatal 
asystole by the one drug, quickly and rapidly 
restored to health by the other. Most usually 
this ingravescent asystole is a terminal phenome- 
non, and death long prepared for comes often 
unexpectedly at the last, the ingravescent asystole 
suddenly becomes complete. 

Sundry medicinal agents also produce tachy- 
cardia when given in poisonous doses. Digitalis, 
for instance, when given in too large doses, or 
in doses too closely approximated, paralyzes the 
vagus and sets free from control the heart's idio- 
motor mechanism. If this paralysis comes on 
slowly, we have, first, a slow pulse with an occa- 


sional quick beat; by and by the pulse becomes 
quick with an occasional slow beat, or an inter- 
mission; and finally, when the regulating power 
is entirely lost, the intermissions disappear, and the 
pulse becomes regular but very rapid, the heart's 
sounds are embryocardiac, — reduced to a mere 
tic-tac, — the arterioles are dilated, and the blood 
pressure low. 

Belladonna and Atropine in moderate doses in- 
crease the quickness, fulness, and force 
How digitalis, ^^ ^^^ pulse; they also increase the 

belladonna, ^ •' _ it. 

and atropine blood pressure. In toxic doses both 
induce tachy- ^^ these drugs paralyze the vagus, the 

heart runs off, and the pulse becomes 
extremely rapid, feeble, and often irregular. 

Reflex tachycardia is generally of short durar 
tion, and is rarely attended by any danger. Reflex 

tachycardia is usually accompanied by 
Reflex tachy- Q^her neurotic symptoms, such as dila- 

caraia, its j s: • 

symptoms. tation of the pupils, flushing of the 

How they are ^ ^gg ^^ ^^^^ ^^ ^^^^ ^^^ y^^ 

produced. ' ^ •' 

or outbreaks of perspiration, local or 
general. These symptoms certainly indicate reflex 
action through the sympathetic system, but we 
must not, therefore, conclude that the tachycardia 
itself is produced by action on the accelerators 
alone, though there are certain other symptoms 
which seem also to point to this conclusion. For 


example, we find in reflex tachycardia that the 
heart's impulse is forcible and the pulse full, in- 
stead of both being feeble and the pulse small, as 
in ordinary tachycardia due to vagus inhibition. 
But we must not forget that the same thing also 
happens occasionally in tobacco poisoning, in which 
the heart hurry is undoubtedly due to vagus inhi- 
bition. In fact, remembering the trifling results, 
so far as tachycardia is concerned, which follow 
excitement of the accelerators alone, and also the 
fact that certain causes of reflex tachycardia do 
in other circumstances act as vagus inhibitors, the 
conclusion is forced upon us that in certain cir- 
cumstances, not yet clearly understood, the same 
cause that inhibits the vagus also excites the 
augmentors, so that we have at one and the same 
time an idiomotor tachycardia from vagus inhibi- 
tion, and a forcible heart-beat and a full radial 
pulse from excitation of the augmentors. In ordi- 
nary circumstances the vagus acts as the pendulum 
of a clock — it regulates the motion; when its 
action is inhibited, it is as if the pendulum were 
removed, and the idiomotor mecha- 

Diference be- 

nism of the clock allowed to rattle tvJeen 

on at an uncountable rate. This is "■"^^'^fie^ 

tachycardia pure and simple. But 

when the pendulum is only shortened, not re- 
moved, the rate indeed is quickened, but consider- 


able force of beat remains; this is reflex tachy- 

There is nothing abnormal either of neurotic or 
organic origin which may not act as an excitant 
to an attack of tachycardia. Every kind of emo- 
tion or psychical impression ; all sorts of neuroses, 
hysteria, epilepsy, neurasthenia; every form of 
dyspepsia; affections of the liver, only rarely; 
floating kidneys ; prostatic disease ; abdominal 
tumours, intestinal worms; various forms of neu- 
ralgia ; also uterine affections of divers characters, 
— may all at times prove the exciting causes of 
paroxysms of heart hurry of shorter or longer 
duration, and in women these are most prone to 
occur during amenorrhcea and at the menopause. 
Affections of the lungs, and especially of the 
heart, are also well-known causes of tachycardia ; 
and when the heart affection is a mitral stenosis, 
the heart hurry often persists for many years 
apparently without any serious detriment to the 

Whatever may be the exciting cause of the 
attack, there is no doubt that any breakdown in 
the general health, any anaemia that may be 
present, whether from increased hsemolysis or de- 
fective hsemogenesis, is a most powerful predis- 
posing cause, especially if conjoined with that 
gouty venosity always present after middle life. 


Tachycardia of purely emotional origin is often 
very persistent in its duration. In the case of a 
middle-aged lady in whom the attack was brought 
on by severe mental emotion of some duration 
culminating in a tragedy, it persisted for years, 
ultimately dying quite away. In this case the 
tachycardia was followed by a threatening of sym- 
metrical gangrene of the finger-tips, which also 
was perfectly recovered from.^ 

Antecedent sources of emotion are common 
enough causes of tachycardia, but the connection 
is not always very obvious to the suf- ^^^ ^^^^ ^j. 

ferer, and in all the complaints made emotional 

., 11 I, j.T_ J. J.1 J. • tachycardia. 

it usually happens that the most im- 
portant is never touched upon at all. In the case 
just referred to, the patient was almost well before 
the source of her sufferings was ascertained. 

The following case was of a similar character. 
This patient, a clergyman, consulted me several 

1 Raynaud's disease — another neurotic affection, of which 
this is the single instance out of many observed that showed 
any affinity to tachycardia. Symmetrical gangrene is more 
allied to those curious vaso-motor affections in which there is a 
persistent feeling of coldness, either local or general, which it 
is difficult to remove or even alleviate. The coldness seems to 
be due to actual constriction of the vessels. One of my patients 
died during the winter of what might be termed a universal chil- 
blain. A feeling of local coldness, as well as pain, frequently 
precedes, generally accompanies, and is apt to follow even a 
threatening of vaso-motor gangrene. 


years ago for rapid, irregular action, affecting a 
heart somewhat dilated and also hypertrophied. 
The trifling irregularity soon disappeared, and a 
spell of tachycardia set in that lasted, with some 
remissions, for a period of nearly four years. Dur- 
ing all this time the pulse was continuously ex- 
tremely rapid and feeble, the heart's impulse weak, 
and its sounds embryocardiac in character. With 
my finger on this feeble, rapid pulse, I have often 
felt it run off into a scarcely perceptible tremor, — 
pulsus myurus, — and while wondering whether it 
would ever return, it would suddenly come back 
with a feeble thump and continue on as before, 
the patient remarking, " That was one of my 
peculiar attacks," but never saying that he felt 
faint. Indeed, one of the most remarkable facts 
connected with this case was, that with a pulse so 
rapid — ■ never under 130 — and feeble, there was 
so little uneasiness or distress, and that the patient 
was able to go about very much as usual. Under 
appropriate treatment, coupled with several months' 
relief from duty, he was so. far restored that at the 
end of two years he felt himself able to accept the 
most dignified position which his Church had in 
its power to bestow. And I may add that he dis- 
charged the somewhat onerous duties of this posi- 
tion not only with dignity and ability, but to the 
entire satisfaction of his friends and of his Church. 


Nearly two years subsequently he died from an 
attack of pneumonia, the result of exposure to 
cold after exertion in early spring, having been 
wonderfully free from heart symptoms for some 
time previously. Indeed, the heart, being slightly 
hypertrophied, was not specially at fault at the 
last, though more than sixty years' service and all 
it had come through had not tended to improve its 
power of resistance. 

The remarkable part of the case is this: that 
here we had a perfectly healthy man, leading a 
model life, and doing only the ordinary work of 
a country clergyman, which few would consider 
either hard or excessive, suddenly struck down 
with a serious attack of tachycardia engrafted 
upon a dilated and hypertrophied heart. There 
was an entire absence of all the usual causes of 
enlargement of the heart. There was no disease 
of the valves, no marked arterio-sclerosis, and 
therefore presumably no affection of the coronaries. 
There was no affection of the lungs or kidneys, 
nor had there been any undue exertion. The 
patient was well developed, and had reached ad- 
vanced age in perfect health, so there was no 
reason to suspect abnormal narrowness of the 
aorta. Further, he was a most temperate man, so 
excess of any kind could not be alleged as a cause, 
and, so far as I could learn, there was no reason 


to suspect any hereditary tendency.^ But he was 
over sixty, and the vascular changes which age 
brings on every one must have considerably pro- 
gressed, when he was suddenly assailed by the 
most terrible bereavement which can befall any 
man. Then he began to age rapidly, and eighteen 
months subsequently he consulted me with the 
symptoms already described. Evidently the heart 
labouring, as all hearts do more or less under the 
strain thrown upon it by the loss of arterial elas- 
ticity, had its contractility impaired by the inhib- 
itory emotional influence conveyed to it through 
the vagus. It must also at this time have suffered 
somewhat from impaired nutrition, and all these 
circumstances must have combined to produce the 
dilatation which was speedily followed by slight 

The heart hurry in this case did not die off 
in a few weeks or months, as is commonly the 
case in attacks of paroxysmal tachycardia, but 
persisted for years ; and this we can scarcely 
wonder at when we remember that the cause 
was not only a powerful, but a persistent, emo- 

1 Vide, Traube, Gesammelte Beitrage sur Pathologie und 
Physiologie, Berlin, 1878-9 ; Striimpell, Lehrbuch der Speciellen 
Pathologie und Therapie, Leipzig, 1883, Erster Band, S. 422 ; 
and Oscar Fraentzel, Die idiopathische Serzvergrosserungen, 
Berlin, 1889. 


This case is instructive as showing, in the first 
place, how efficient a cause of cardiac enlargement 
the mere natural loss of arterial elasticity is, even 
in those who are perfectly healthy and temperate. 
Just the other day I saw an old gentleman of 
eighty-two ; in all his long life he had never ailed. 
He was of most temperate, almost abstemious^ 
habits ; up to a few months ago he thought noth- 
'ing of walking five or six miles over a rough, hilly 
road, and was never breathless. I saw him for 
breathlessness due to pulmonary congestion fol- 
lowing influenza, and, to my astonishment, found 
his heart dilated and hypertrophied, beating with 
a heaving, forcible impulse in the fifth interspace, 
considerably to the left of the nipple. As I had 
known this gentleman all my life, the condition of 
his heart was quite a revelation to me, and a very 
remarkable proof of the efficiency of natural causes 
in giving rise to cardiac enlargement, which in his 
case, even more than in most, seemed to deserve 
the adjective "idiopathic." The key to this case, 
as well as to all similar cases, lies in the structural 
change of the senile arteries, and in the fact that 
all such hearts are not simply hypertrophied, but 
are dilated and hypertrophied. Even Cohnheim 
has said that " the great majority of all idiopathic 
cardiac hypertrophies are eccentric," and that 
" non-eccentric hypertrophy has chiefly a theoretic 


interest," ^ — a statement that might be even more 
strongly emphasized. 

In the second place, this case is interesting as 
showing how readily the erethism of a weak and 
labouring heart may pass into alarming, if not 
actually serious, tachycardia, under the influence 
of an overwhelming emotion. 

And, lastly, this case furnishes a most remark- 
able example of the small amount of actual 
suffering entailed by even a most severe attack 
of tachycardia, and how wonderfully little the 
habits of life may sometimes be disturbed by what 
seems even to an expert to be a most serious car- 
diac affection. 

To conclude, as vagus inhibition is the great 
cause of tachycardia, intra-thoracic tumours, often 
of no great size, pressing upon or involving the 
vagus in their structure, are well-known causes 
of persistent heart hurry, not simply paroxysmal, 
but fatal. 

"^Lectures on O-eneral Pathology, New Sydenham Society's 
Translation, London, 1869, Vol. i. , pp. 70, 71. 



Laennec, the earliest of auscultators, has said, 
" We can distinguish two kinds of intermissions : 
the one real, consisting in an actual suspension of 
the heart's contractions ; the other /aZse, depending 
on contractions so feeble as to be imperceptible, or 
almost imperceptible, to the touch in the arteries." ^ 
And Hope has supplemented this by stating that 
" when one or two beats are regularly and perma- 
nently imperceptible in the pulse, such cases con- 
stitute the bulk of those in which the pulse is 
described by non-auscultators as being singularly 
slow — for instance, thirty or twenty per minute." 
And he adds, "In a few rare cases, however, it is 
really slow." ^ So far as my own experience goes 
the rarity has been all the other way, as I have 
seen many more really slow hearts, than hearts 

1 A Treatise on the Diseases of the Chest, and on Mediate 
Auscultation, translated by Jolin Forbes, M.D., 2d edition, 
London, 1827, p. 570. 

^ On Diseases of the Heart, 3d edition, London, 1839, p. 377. 


beating at the normal rate with an abnormally slow 

pulse, due to alternate hemi-sy stoles. 

Slow pulse '^ _ 

fromhemi- There is never any difficulty in mak- 
systoie. -j^g ^ diagnosis between the two varie- 

ties of slow pulse ; we have but to count heart 
and pulse together to realize that in the one 
class of cases each heart-beat, few and far between, 
is followed by a distinct pulse at the wrist, while 
in the other set a varying number of cardiac pulsa- 
tions never reach the periphery. Sometimes every 
alternate beat is dropped, and at others two or 

The first case of this kind that came before me 

was that of an old lady with a gouty history, but 

who had never had a regular attack, 

Case of false ^j^^ ^^g suddenly seized, while shop- 
oradyearaia. _ j ' x^ 

ping, with what seemed to be an epi- 
leptic fit. In spite of what was supposed to be 
appropriate treatment, these seizures continued to 
recur whenever she made the slightest exertion, 
and when I saw her she was unable to rise from 
the recumbent position without bringing on an 
epileptiform attack. Upon examination, I found 
her pulse beating only 20 per minute, while her 
heart was beating at the rate of 60; only every 
third beat was strong enough to reach the periph- 
ery. The heart was dilated, with a feeble impulse, 
but without any murmur; the aortic second was 


accentuated. Remembering Stokes' admirable 
essay on the connection of pseudo-apoplectic 
attacks with the feeble circulation that he believed 
to depend upon fatty degeneration of the heart,i 
there was no difficulty in connecting the epilepti- 
form seizures with the state of the heart, and just 
as little difficulty in determining upon the appro- 
priate treatment. The result was most satisfac- 
tory — the old lady, who had been looked upon 
as the victim of serious senile epilepsy, had no 
more attacks. Within a week she was able to 
entertain some friends at dinner, and she lived for 
several years without any recurrence of her serious 
symptoms, dying gradually at last from asthenia. 

Hearts, however, which are really slow belong 
to quite a different and a much more serious cate- 
gory. Several years ago I received the following 
letter from a professional friend : " A medical 
man in this neighbourhood, in extensive first-class 
practice, knowing that I had been your resident 
physician, asked me to examine his heart. What 
rather troubled him and made him 
think of his health was, that formerly IZ^^^Z. 
his pulse was always 60, and that now 
it is invariably 48, except sometimes after dinner, 

1 Dublin Quarterly Journal of Medical Science, Vol. xi., 1846 ; 
also Diseases of the Heart and Aorta, Dublin, 1884, pp. 322, 
362, etc. 


if he has taken a little champagne, when it reaches 
60 again. He has arcus senilis (age 53) well- 
marked, but nothing remarkable in the radial or 
temporal arteries, and is as active and energetic 
as possible. Lately I have noticed that he often 
looked tired and worn out, but he says he is not 
overworked. I carefully examined the heart, and 
found nothing except feeble apex-beat and sounds. 
His temperature does not, as a rule, come up to 
98°. I tell you this, because Sir William Jenner 
told him that he had noticed that men with a slow 
pulse and rather low temperature live a long time. 
This gentleman does not feel at all ill, but is 
anxious to know whether his slow pulse (so much 
slower than formerly) ought to be looked upon 
as indicating degenerative changes in the heart 
and vessels ; and if so, whether it would be wiser 
to knock off some of his work, which he can easily 
afford to do." My reply to this was, that the signs 
and symptoms detailed were evident indications 
of cardiac failure ; that the heart, so far as my 
experience could enable me to judge without a 
personal interview, was beginning to dilate, that 
the arteries had undoubtedly lost their elasticity, 
and were probably even more atheromatous than 
was suspected. I advised considerable lessening 
of his daily work, and indicated the lines upon 
which the treatment should be conducted. This 


patient acted as advised; he survived for nearly 
nine years, and w^as then found dead in bed one 
morning when on a yachting tour. 

A pulse of 48 is, of course, only abnormally slovs^ 
in relation to the normal pulse of the individual, 
because, though 70 to 75 may be reckoned the 
normal pulse of most, there are some whose pulse 
•never rises above 60, and a few — a very few — 
whose normal pulse is never even up to 48, and 
who yet enjoy perfect health. Haller tells of tAvo 
people whose radial arteries did not beat oftener 
than from 24 to 30 times a minute ; and M. Roux 
relates the case of an agriculturalist who had gone 
through his military service without difficulty, 
who never had a complaint either cardiac or cere- 
bral, and who was a typical example of good 
health, and yet his pulse-rate was never over 34 
to 40 per minute, and even a run of several min- 
utes never raised it higher than from 50 to 55, 
and that only for a few seconds.^ Several similar 
cases have been recorded, the most remarkable 
and best known being that of the great Napoleon, 
whose pulse, according to Corvisart, was only 40 
per minute. Napoleon is often cited as an ex- 
ample of a slow pulse combined with perfect 
health ; but Napoleon was an epileptic, like many 

1 Vide "Le pouls lent permanent." Par le docteur E. 
Leflaive. Gazette des Hopitaux, 1891, p. 1072. 


— if not most — of the sufferers from brady- 

Slow pulses are rarely to be found in early life, 
but occasionally they are found even at so early 

Brodvoaraia ^^ ^g^ ^^ ^^^ J^^^^ 5 some of these 
may be physi- youthful cascs are apparently phys- 
ogica . iological and attended with perfect 

health, but the larger number at any age are 
strictly pathological, not only in their origin, 
but also and specially in their results. Rare at 
all ages, bradycardia increases in frequency and 
danger after middle life, and is more common 
among men than women. All the cases I have 
seen have been men. 

The earlier observers — Adams,^ Richard Quain,^ 
and Stokes ^ — endeavoured to connect sequen- 
tially a slow heart with fatty degen- 
frequently eratiou of the myocardium. Indeed, 
pathological ^he sole survivor of these three still 

and senile. 

quotes slowness of the pulse as a 
symptom of this affection, acknowledging at the 
same time that quickening of the pulse increasing 
with age may also be an important indication of 
the same pathological condition.* But the very 

1 Dublin Hospital Reports, Vol. iv., 1827. 

2 Medico- Chirurgical Transactions, Vol. xxxiii., p. 162. 
" Op. at., p. 326. 

i Dictionai-y of Medicine, p. 595, 1882. 


antagonism of the two symptoms precludes the 
idea of the connection of either with sradycaraia 
a fatty myocardium being anything not a result of 
but purely accidental. Indeed, a simi- ^f *^'^"7 

'- •' ' ation, nor of 

lar statement may be made in regard any other ear- 
to atheromatous disease of the heart, 
aorta, or coronai-ies, as well as all other cardiac 
and vascular affections with which a slow pulse 
has been incidentally found connected. These 
lesions are all so much more frequently found 
apart from a slow pulse than with it, that it seems 
much more reasonable to conclude that the appar- 
ent connection is merely accidental, than that 
there is any direct relation of the one to the 
other. This is quite distinctly the case even in 
regard to the only lesion which is always present 
in every case of senile Bradycardia — dilatation 
and hypertrophy, the dilatation predominating. 
Slow pulses are rare, but after middle life dilata- 
tion and hypertrophy of the heart are of every- 
day occurrence. 

Inhibitory impulses, we know, pass through the 
inhibitory centre down the vagus to the heart; 
these slow the heart and diminish its excitability. 
Roy and Adami tell us that there is a limit to this 
slowing, and that after a longer or shorter period 
the ventricles start off on an independent rhythm 
of their own (vide antea, p. 39). Accident, how- 


ever, frequently carries out experiments which are 
more suggestive and often more fruitful than any- 
contrived by art, and this seems to be specially 
true in relation to the causation of slow pulse. 

Surgical observers have long since recognized 

that fracture of the cervical vertebrte, especially 

of the fifth or sixth, frequently gives 

Relation of \^ 

injury of the ^se to slow pulse. Gurlt says that 

cervical cord fractures even as low down as the first 
to slow pulse. 

dorsal vertebra may have this result, 

and that the pulse may fall as low as 36 or even 
20 per minute ; ^ and Charcot states that retarda- 
tion of the pulse is one of the most interesting 
and least noticed facts of the symptomatology of 
cervical spinal lesion.^ 

Jonathan Hutchinson tells us that unless injury 
to the spine is in the cervical region, no influence 
on the heart's action is ever observed. But he 
states that if the fracture is high up, the cardiac 
pulsations are greatly diminished in frequency, 
while (from the paralysis of the artery) the pulse 
itself is remarkably full and large. He adds 
that it is very remarkable to see a man scream- 
ing with pain and obviously suffering acutely. 

^ Handbuch der Lehre von den Knochenbruchen, 1864. 

'■' Lectures ore the Diseases of the Nervous System, by J. M. 
Charcot, New Sydenham Society's Translation, London, 1881, 
p. 117. 


with a full, slow pulse, beatihg not over 48 per 

Rosenthal has recorded the case of a girl of fif- 
teen who received a blow on the region of the sixth 
cervical vertebra. This was followed by symptoms 
of slight and quite transitory cerebral shock, ac- 
companied by hemiplegia of the right side, which 
did not last longer than twenty-four hours. But 
for four weeks subsequent to the injury, the pupil 
(presumably the right, but which is not stated) 
remained dilated, and the cardiac pulsations oscil- 
lated between 56 and 48. The patient recovered 

This fact of slow pulse following injury to the 
cervical cord, and passing off when that injury is 
recovered from, may, I think, be very instructively 
considered in connection with Holberton's well- 
known case, in which the injury to the cervical 
cord was not direct, but the result of inflammatorj'- 
action, and in which it took two years to develop 
retardation of the pulse. 

This gentleman, aged sixty-four, was thrown on 
his head in the hunting-field in December, 1834. 
At first he was stiff and sore, with great pain in 
the neck, about the cuneiform process and the 
condyles of the os oeeipitis. The pain continued 

1 London Hospital Beports, 1866, p. 366. 

2 Charcot, op. cit., p. 117. 


about six weeks. At the end of a year, he was 
well, in excellent spirits, but still complaining of 
a difficulty in moving his head. 

In January, 1837, he had a fainting fit when out 
walking, and the medical man who attended found 
his pulse to be only 20 in the minute. His usual 
pulse was now found to be 33, but often during a 
fit it fell to 20, 15, or 8 in the minute, and even 
when not in a fit, it was occasionally as low as 7-|- 
per minute. His syncopal attacks always ended 
in epileptiform seizures, and as time went on, they 
increased in frequency as well as in severity. His 
first alarming succession of fits occurred in June, 
1838, and his last and fatal attack was in April, 
1840. After death his heart was found to be en- 
larged, the walls of the left ventricle were rather 
thin, the valves healthy, the auriculo-ventricular 
opejiing dilated. No ossification or calcareous de- 
posit was found in any part of the vascular system. 
The inflammatory action which had followed the 
injury to the first and second vertebrae had nar- 
rowed the foramen magnum and upper part of the 
spinal canal, compressing and increasing the density 
of the medulla oblongata and upper part of the 
spinal cord. This gentleman never had any par- 
alysis, never after the first few weeks suffered pain 
in the neck. His spirits when free from attacks 
were excellent, and his general health often very 


good. During the last three or four years of his 
life he was liable to cold feet, and suffered from a 
feeling of general chilliness. ^ 

These cases which so markedly connect slight 
and transient injury (concussion) of the cervical 
cord with temporary slowness of the pulse, and 
more serious and permanent injury of the same 
part of the cord with permanent slowness of the 
pulse, leave no room for doubt that through this 
centre it is possible to convey to the heart an 
inhibitory influence, powerful enough to bring its 
pulsations down to 7J beats per minute, and per- 
sistent enough to last for many years. 

Eoy and Adami tell us that vagus inhibition 
may arrest ventricular action altogether 

. Difference be- 

f or a short period, but that it does not tween vagus 
persistently slow the heart, because """^ cervical 

■■^ . inhibition. 

sooner or later a time arrives when 
vagus inhibition is set at naught, and the ventricles 
start off on a rhythm of their own, an idio-ven- 
tricular rhythm ^ (^vide antea, p. 39). But cer- 
vical inhibition, as we may call it, is not only strong 
enough to force a slow rhythm upon the heart, but 
is also powerful enough to compel the heart to 

1 "A case of slow pulse with fainting fits, which first came 
on two years after an injury to the neok from a fall." By 
T. H. Holherton, Medico-Chirurgical Transactions, London, 
1841, p. 76. 

2 Op. cit., p. 233. 


keep to this slow rhythm for years, with but tri- 
fling variations. For years the heart may pulsate 
at the rate of 20, 30, or 40 beats per minute, with- 
out ever quickening its pace, without an inter- 
mission, or even a hint at irregularity. It seems 
as if the whole heart, sinus, auricle, and ventricle, 
were forcibly controlled and compelled to keep 
steadily to the unnatural rhythm. Now and then, 
as in Holberton's case, we have an occasional in- 
termission. Still more rarely we have a bout of 
irregularity interposed, as in a most interesting 
case which I shall presently relate. But as a rule, 
the steady, slow, funereal beat never varies from 
the time it commences till the patient's death. 

If we ask why the cervical cord should have so 
potent an influence upon the heart, there seems to 

be but one possible answer: Because 
Region of cer- . . 

vicai cardiac from this region the spinal accessory 

inhibition is arises. This nerve rises by several 

that from 

lohich the roots, beginning as low down as the 

.acces- sixth cervical vertebra; it runs up 
sort) arises. 

within the spinal canal through the 

foramen magnum into the cranial cavity, and 
thence it passes out through the foramen lacerum 
posterius in close proximity to the vagus. The 
internal portion of the spinal accessory subse- 
quently joins the vagus and is distributed to the 
heart, presumably as its motor nerve. The vagus 


and the nervus accessorius resemble a spinal nerve, 
the vagus with its ganglion being the posterior or 
sensitive root, while the spinal accessory is the 
anterior or motor root. Concussion of the cord 
at the origin of the spinal accessory produces tem- 
porary slowness of the pulse ; severe injury to that 
part of the cord, disease of the cervical mem- 
branes, or of those at the base of the brain (pachy- 
meningitis), involving injury or compression of 
the accessory nerve, produces permanent slowness 
of the pulse. Besides these direct injuries there 
are various reflexes and several poisons which are 
supposed to have a retarding influence upon the 
heart. The Indian fakeers, it is alleged, slow the 
heart and diminish the force of its beat by volun- 
tary compression of the muscular branches of the 
nervus accessorius in the neck (vide antea, p. 67). 
Various cases of slow pulse have been recorded 
in connection with abscess of tlie brain ; gastric 
irritation and constipation often precipitate the 
syncopal attacks, and by some have been supposed 
to be the only exciting cause. In one of my own 
cases alcoholic excess was the only pos- g^^^^j-^ ^„.^j„. 
sible cause that could be discovered, tion and mn- 
Holberton's patient had his first serious p^g^^ocativlT 
attack the day following a heavy din- of syncopal 
ner, when, as Holberton says, he " had 
eaten heartily of a variety of substances," and 


with him both gastric irritation and constipation 
were found to be serious provocatives of syncopal 
attacks, and they always affected the pulse-rate, 
either raising it or lowering it, and, strange to say, 
the one was as liable as the other to be followed 
by an attack. Burnett also records a case of slow 
pulse with epileptiform seizures, in which the only 
discoverable cause was disturbance of the chy- 
lopoietic viscera ; and he quotes two similar cases 
from Morgagni, in which no other cause could 
be discovered. In Burnett's own case the pulse 
ranged from 14 to 28, though it occasionally rose 
to 56.1 

Several of my patients have died in syncopal 
attacks, but I myself have never seen such a seiz- 
Gharacterof "^^- Holberton describes a fit as al- 
a syncopal ways preceded by cessation of the 

attach. 1 J? 1,11. 

pulse tor a second or two before syn- 
cope took place; on the heart recommencing to 
beat, "the face would redden, and consciousness 
return with a wild stare and occasionally a snort- 
ing, a slight foaming at the mouth, and a convul- 
sive action of the muscles of the mouth and 
face." 2 

The initiatory seizure seems thus to be essen- 

1 " Cases of Epilepsy attended with Remarkable Slowness of 
the Pulse," by William Burnett, M.D., Medico-chirurgical 
Transactions, 1827, p. 202. 2 ^og_ gj-{_^ p_ 79^ 


tially syncopal in character, while the succeeding 
phenomena are evidently due to the unusually 
large blood-wave with which the tissues are sud- 
denly flushed on what may be termed the return 
of life. 

But however effectual affections of the chy- 
lopoietic viscera may be in the production of syn- 
copal attacks when a slow pulse alreadv „ ^ , 

■^ i. J Eeflex heart 

exists, the numbers of disturbed stom- retardation 
achs and constipated bowels that are '^'^'"^■f^'- 
found apart from any retardation of the pulse, 
make it extremely doubtful — to say the least of 
it — whether of themselves these conditions have 
any material effect in slowing the pulse. And the 
same remark may be made in regard to all those 
reflexes to which retardation of the pulse has been 
assigned as a symptom. More definite informa- 
tion as to this is still a desideratum. 

We know that many poisons, both organic and 
inorganic, bile, uraemia, diphtheria, digitalis, lead, 

etc., slow the heart, but these all have 

a direct action upon the nerves, and of the pulse 

upon the nerve-centres.^ Indeed, all Probably ai- 

■*• _ ways due to 

the information at present at our com- direct action 

mand seems to point to direct action "" *''^ newm 
^ accessorius. 

on the spinal accessory in the neck or 

1 Greenhow mentions a remarkable case of slow pulse with 
paralysis following diphtheria, in which the large nerves of the 


chest, before or after its junction with the vagus, 
whether by concussion, compression, or otherwise, 
as undeniably the most potent, and probably the 
only cause of abnormal or pathological brady- 

Hemi-systole has already been mentioned as a 
cause of apparent slowness of the pulse, because 
only every second or third beat is strong enough 
to reach the periphery. The following sphygmo- 
gram represents this condition. In it (Fig. 6) 

Fig. 6. 

the pulse is seen to rise at once to its full height ; 
the secondary dicrotic wave occupies its usual 
position, but lower down the descending limb — 
just where in a normal tracing the elevation of a 
new pulse ought to begin — there is a slight ele- 
vation (a) due to the hemi-systole, imperceptible 
to touch and not always to be found in the tracing. 
In true bradycardia the sphygmogram is per- 
fectly different. In it (Fig. 7) there is what 
appears to be a great round-topped predicrotic 

limbs were painful to touch ; the natural inference is that prob- 
ably the spinal accessory was similarly affected. Recovery was 
complete. — Lancet., 1872, Vol. i., p. 615. 


blood-Wave, as if the blood pressure was greatly 
increased, or as if the rigid arterial wall was only 
slowly raised by the advancing blood-wave. 

Fig. 7. 

The true explanation is as follows : So long as 
the circulation remains intact, the heart 
gets more distended the longer the ^^^P'f""'*"" 

^ ° of a orady- 

diastole is prolonged. At each systole cardiac 

a larger blood-wave than usual is ^''2""°- 

° gram. 

thrown out, and as the arteries have 
had a longer time than usual to empty themselves, 
it passes rapidly onwards, and as can be readily 
understood, the secondary dicrotic wave is not 
only of greater amplitude than usual, but it also 
occurs earlier on the descending limb. In the 
sphygmogram (Fig. 7) the point A marks the 
height of the pulse-wave. The round top follow- 
ing is not, as might be supposed, the pulse-wave 
itself, but is really the secondary or dicrotic wave 
placed near the upper part of the descending limb 
instead of about its middle. In some sphygmo- 
grams, this dicrotic wave is so ample and so 
premature that it appears to occupy the very sum- 
mit of the wave, the true apex of the pulse-wave 


lying below it, so that the tracing has an anacrotic 

The large blood-wave sent on is naturally asso- 
ciated with a temporary rise of blood pressure, 
which rapidly dies off through the continuous out- 
flow through the arterioles during the prolonged 
diastole. Hence in bradycardia we have, as in 
aortic regurgitation, an abnormally high blood 
pressure alternating with an exceptionally low one. 
A knowledge of this explains much that seems 
anomalous in the history of bradycardia, and it 
has also a not unimportant bearing on the treat- 
ment of such cases. 

In the sphygmogram (Fig. 7), the pulse-rate was 
32, but it varied from 36 to 28, and in this patient, 
as in all the senile brady cardiac hearts I have ever 
,,.,,, seen, there was marked dilatation of 

Senile orady- 

cardiaprob- the heart, extension of the precordial 
tl^atT dulness, apex-beat to the left of its 
with cardiac usual position, and always a mitral mur- 

dilatation. n , t 

mur — generally a systolic murmur — 
in all the areas. Knowing as we do the very high 
blood pressure the heart has to cope with shortly 
after the commencement of systole, the fact that 
most of these slow hearts belong to the latter half 
of life, and that the heart, in common with the other 
tissues suffers in its nutrition from the extremely 
low blood pressure prevailing during diastole, and 


suffers most just when it is called upon to make 

its greatest exertion, we cannot wonder that such 

hearts are always dilated. They also hypertrophy 

— never much, but a little — quite sufficient to 

enable them to carry on the circulation. I have 

never seen any reason to regard the myocardium 

of these slow hearts as specially feeble, — rather the 

reverse. But sufferers from senile bradycardia are 

generally sluggish and inert, which is perhaps not 

to be wondered at. 

About a dozen years ago I received the following 

letter: " In autumn, 1875, after a time 

of much anxiety, I fell down and was '^"^^°J' 

■' bradycardia. 

unconscious for two minutes, with a 
very slow pulse. At various times after that, in 
1877 and in 1878, I had turns of faintness, ac- 
companied by great slowing of the pulse, which 
resumed its natural pace when the faintness wore 
off. In November, 1879, the pulse got down to a 
steady slowness of 36 per minute. A course of 
quinine and iron was tried without any good effect. 
My friend, Dr. Dobie, of Chester, then prescribed 
for me, and after about six weeks, about the mid- 
dle of February, the pulse was suddenly restored 
fj'om 36 to 70, and continued at its usual rate all 
March, but in April it fell gradually back to 36, 
keeping remarkably steady at that figure. Occa- 
sionally, for a few minutes at a time, it rose to 40 


or fell to 28, but it speedily returned to 36 as its 
normal rate, which it has ever since maintained. 
During June and July, I again tried Dr. Dobie's 
prescription, but without any good effect. In 
August I went to Harrogate, and by Dr. Myrtle's 
advice took Kissingen water. At the end of a 
week he supplemented this with chloride of iron 
water. At the end of another week I had become 
rapidly weak, and Dr. Myrtle ordered me to abandon 
this prescription. Since then I have abandoned 
all treatment, and continue very weak. This day, 
at early morning, my pulse was 30 ; while I write 
it is 36." 

This letter was speedily followed by a personal 
visit from the patient himself, and I find, from 
notes taken at the time, that he had a weak dilated 
heart, with a loud systolic mitral and tricuspid 
murmur; pulse ranging from 36 to 40; no albu- 
minuria. He made but little progress while under 
observation, the pulse still continuing slow, and he 
was lost sight of in a few months. Being lately 
— 1890^ — -desirous of ascertaining the result, I put 
myself in communication with the patient's friends, 
and received from himself the following letter : 

" I seem to have sent you an account of my ill- 
ness in 1880, so I need not notice it previous to 
that date. 

" During the years 1881, '82, and '83, the pulse 


continued from 30 to 34, accompanied by great 
exhaustion. During these years I gave up all 
treatment of any kind, living in my usual way, 
without anj-- medical advice whatever. 

"About the end of November, 1883, I was 
amusing myself with a little grandson from India, 
and had a good deal of laughing and fun with 
him. A change seemed to have come upon the 
long dreary tramp of 30, with its solemn regular- 
ity; it had now become of the most irregular 
character, ranging from 30 to 80. A strong beat, 
then five or six very small ones all in a rabble, 
like the bursting of a wooden barrier across a 
river, with masses of the debris gathering again 
and obstructing the current for a time, and then 
bursting through again. At the end of about a 
week the irregularity ceased, and at the end of 
1883 it was moving quite naturally at 70. 

" This improved state of things continued for 
several months, when it began again to slow down 
to the thirties, where it has continued ever since ; 
the highest record of this period being about 36, 
and the lowest, 28. One peculiar feature of this 
slow pulse is its regularity; in some conditions 
36 can be depended upon, in some 34, and in 
some 32. It does not often come below this, 
although 28 has been recorded several times. 
While I write my pulse is perfectly steady at 36. 


I have been much troubled with sleeplessness, 
caused by twitching or flickering of the legs, 
accompanied by great depression of spirits ; but 
in another three months I shall, if spared, have 
lived the threescore and ten, which most people 
admit is quite long enough. I always looked well, 
having a very florid complexion, with a good deal 
of blue, however, in it. I have not fallen down 
again to be insensible as I was at the first, but 
have been glad to stretch myself out on the road 
sometimes, so as to avoid what appeared to be 
a fainting turn coming on." 

This patient died two years subsequently in a 
syncopal attack, his heart having been irregular 
for some time previously, in this way: that for 
one while the beats were very slow, and again, 
for another while, faster, but always slow. There 
was no examination of the body. 

I am not aware of any other case of true brady- 
cardia in which marked irregularity was even an 
occasional phenomenon, but to my knowledge 
there is no other recorded experience of the effect 
of unwonted exertion on a heart of this character. 

The effect so graphically described seems to 
have been the result of the unwonted exertion 
forcing the ventricles into an independent rhythm. 
When the systole of that independent ventricular 
rhythm happened to coincide with the systole of 


the auricle, then there was the occasional " strong 
beat " referred to ; while the " rabble " of five or 
six small beats were the result of ventricular 
systoles which did not coincide with any auricular 

While delirium cordis of this character is an 
unusual symptom in true bradycardia, it is by no 
means uncommon in gouty, dilated 
hearts, at least as a temporary phe- °^^™™ 

^ •> ^ cordis. 

nomenon. It is always desirable in 
all such cases to make a careful comparison 
between heart and pulse, and if possible to take 
a sphygmogram of the latter. Delirium cordis 
is common enough in mitral stenosis, but in that 
affection it is never so striking a phenomenon as 
in the dilated gouty heart. Because in stenosis — 
unless the stenosis is very slight — the difference 
between the size of the beats is never so marked 
as when the auriculo-ventricular opening is at 
least of the normal size. Less frequently this 
delirium cordis in the gouty heart is found to be 
constantly present, never ceasing from its first 
appearance till death occurs. Of my own personal 
knowledge I can only recall three such cases, all 
of them well-marked examples. Two of these 
were well-known professional men, who both died 
from dilated hearts — one at the age of threescore 
and ten, and the other twenty years younger. 


The elder of these had the pulse of delirium cordis 
for twenty years before his death, of my own 
knowledge. I doubt if the younger man suffered 
for longer than about five years, and both con- 
tinued to work till close upon the end with the 
utmost calmness and self-possession. The only 
other example of well-marked and persistent deli- 
rium cordis I can now recall was an old lady 
shown to me as a clinical curiosity, who lived in 
the heart of Westmoreland, and did not seem in 
the least disturbed by her unusual condition, of 
which she was yet fully conscious. 



AccoEDiNG to Quain 80 per cent of all cases 

of angina pectoris occur after the fortieth year of 

life ; there can be, therefore, no hesi- 

Angina pecto- 
tation in regarding it as a symptom ,.^g „ symp- 

of the senile heart. Yet even when torn of the 

childhood is scarcely passed life may 

be cut short with this symptom, and it is equally 

certain that death may then occur from causes 

usually regarded as purely senile in character. 

Tortuous, hard, and atheromatous 

Yet death 

arteries are not uncommon in early from angina 
life, and Dr. Wild of Manchester has ™f-' ""IZ 

when child- 

recorded the sudden death of a girl hood is 

of twelve with advanced sclerosis of s««''ce'»/ 

the coronary arteries.^ She was not 

known to have suffered from angina, but there 
is such a thing as angina sine dolore, and sudden 
death with such a lesion, and without other evi- 
dent cause, may very fairly be attributed to this. 

1 The Manchester Medical Chronicle, July, 1892, p. 230. 


Wild has also recorded the sudden death of a 
girl of nineteen from angina,^ and I myself have 
published a case of death from angina at the early 
age of twenty-four.2 j^q ^gg c^n therefore be 
looked upon as necessarily free from lesions usu- 
ally found in advanced life, nor is any period of 
life always exempt from symptoms commonly 
found in connection with senile lesions. 

The term " pseudo-angina " is often applied to 
anginous pains occurring before middle life, espe- 
cially in the female sex, and yet we 
Angina a g^g ^Yia,t fatal angina may occur in one 

symptom _ ° "^ 

which may who is Still but a girl. To talk of 
occur at any pgeudo-angina is, however, a mark of 
ignorance rather than of refinement 
of diagnosis ; for angina is but a symptom, and if 
well-marked, it should no more be stigmatized as 
"pseudo," because it occurs in youth, than the 
lesion with which it is sometimes associated should 
be called functional because it happens to be 
curable. At the same time there are plenty of 
„ pains to be found about the left side 

Many precor- '^ 

dial pains not of the chest, and even in connection 
anginous. ^-^j^ ^^^ ^^^^^ -^^^-^^^ M^\ach are not 

angina, and these it is of importance to differenti- 
ate for the patient's comfort as well as for his 

1 Op. cit., May, 1889, p. 146. = Balfour, op. cit., p. 300. 


Constipation dependent on torpor of the colon, 
especially if associated with chlorosis, is not infre- 
quently accompanied with neuralgic pains radiat- 
ing from the neighbourhood of the serobiculus 
cordis over the edge of the false ribs, and some- 
times shooting into the cardiac area itself. The 
pain in such a case is constant with occasional 
exacerbations ; it always radiates from some part 
of the colon, and may shoot round the chest, or 
even into the cardiac area, but never upwards or 
into either arm; it is not increased by exercise, 
nor does it get worse during night. The heart 
may have all the usual chlorotic murmurs, but 
the pulse is always soft and compressible. This 
neuralgia is curable, but not always readily so. 

Torpor and congestion of the liver, so constant 
an accompaniment of gastro-duodenal dyspepsia, 
is often associated with pain below either clavicle, 
about the second interspace. This probably arises 
from irritation of the phrenic nerve shooting as 
pain into the upper intercostal nerves. On the 
right side this simulates lung disease ; on the left 
side it is apt to be mistaken for a heart pain. 

Intercostal myalgia and neuralgia often encroach 
upon the cardiac area and get referred to the 
heart ; also acute commencing pleurisy, often free 
from friction because movement is so painful, if 
near the cardiac area, gets talked of as a heart 


pain, though here the thermometer helps to keep 
the diagnosis right. The heart itself often suffers 
from burning, stinging, or cutting pains, the exact 
nature of which it is not always easy to determine, 
but which probably are always either of a rheu- 
matic or gouty character — most probably gouty. 
Finally, there is a cardiac pain dependent upon 
pressure on the cardiac nerves. If the tumour, 
whatever its character, which produces this press- 
ure and pain is too small to be detectable, and 
especially if it occurs in youth or early middle 
life, the pain itself is apt to be stigmatized as 
a spurious angina, as a mere neurotic pain to be 
fought against. And yet the ailment may be serious 
enough to cause sudden death erelong, and of this 
I have seen several instances. It is easy enough 
to separate a pain of this kind from true angina, 
if we get the chance of seeing a paroxysm, but 
then the difficulty begins. In true angina the 
danger is great, and the prognosis always serious, 
because true angina depends upon an interference 
with the function of the katabolic nerve, and in 
its mildest form instantly threatens the citadel of 
life. But in what we may term — for want of a 
better expression — false angina, we have only to 
deal with pain, the danger of which depends upon 
its cause ; if the pain is caused by the pressure of 
a gland, the danger may be but slight; but if it be 


caused by a small substernal aneurism, the danger 
is great and imminent. In a few such cases it is 
possible to make a fairly accurate diagnosis ; in 
others, this is absolutely impossible. There is no 
class of cases in which greater care and circum- 
spection are required, and even with the largest 
experience an error may be committed; for the 
patient's sake it is better to err in excess of cau- 
tion. Various authors — amongst them, Anstie ^ 
and Huchard^ — hare laid down certain rules for 
simplifying the diagnosis between true and false 
angina, Huchard especially has entered very fully 
into the question; but there is not one of the 
many indications commented upon which is not 
liable to serious exception, and with the greatest 
care doubtful cases will always occur in which a 
perfectly accurate diagnosis seems impossible. In 
saying this I refer specially to one case well 
known to myself as well as to others. In the case 
referred to there is no suspicion of hysterical 
exaggeration of any of the ordinary neuralgise, 
described as occasionally implicating the region 
of the heart. This patient was formerly a nurse 
in one of the largest hospitals in Britain, and has 

1 Neuralgia and Us Counterfeits, London, Macmillan & Co. , 
1871, p. 75. 

2 Maladies du Coeur et des Vaisseaux, Paris, 1893, 2me ed., 
p. 719. Huohard has gone very fully into the whole subject. 


been seen in her attacks by some of the ablest 
physicians, who have always treated her as suffer- 
ing from true angina. She has long been happily 
married, though without family, and marriage has 
neither increased nor diminished the frequency 
or intensity of her attacks. During the last 
twelve years I have repeatedly seen 

Case of doubt- ^^^ examined her, and I have always 
fid angma. 

doubted the reality of her seizures. 

She has pain, no doubt, but, though a woman over 
fifty, she is too healthy and blooming to suffer 
from true angina. I have, however, never had an 
opportunity of seeing one of her attacks. Only 
to-day — as I was writing this — she called and 
told me that of late she had been suffering from 
gouty pains in her joints, especially in her fingers 
and wrists ; and she added, " While I have these 
pains I am so irritable that I am a nuisance 
to myself and to every one about me ; and what 
puzzles my doctor as well as myself is that 
while I have these pains I have none of my 
old attacks, but the moment the pains leave my 
joints I get one of my old attacks." Obviously 
this is — after all these years — the clue to her 
case; evidently she has a recurrent gouty neu- 
ralgia of the heart, an angina, no doubt, of a 
kind, yet neither a true nor, properly speaking, a 


As a rule it is not difficult to differentiate all 
the varieties of cardiac pain from angina as well 
as from one another, though, in a doubtful case, 
the observation of an attack — when that is pos- 
sible — may be of the greatest assistance. 

We must not forget that in the syndrome of 
angina pain — even though severe — plays but a 
subordinate part, while in all those other affec- 
tions which simulate it pain is the prominent and 
paramount symptom. 

In a severe attack of angina, the patient dare 
scarcely breathe till the pain abates, not because 
of the pain, but by reason of that awful sense of 
impending dissolution of which the pain is, as it 
were, the subjective symbol. But all attacks are 
not so severe, and a certain amount of jactitation 
is sometimes observed, while in the angina associ- 
ated with aortic regurgitation, forced inspiration 
and violent movements of the arms are occasion- 
ally resorted to with the object of relieving the 
agonizing pain, and sometimes successf ully.^ 

As some of the acknowledged causes of angina 

may be present in the young as well as in the old, 

we are justified in regarding as true 


angina in a angina any paroxysmally recurring 

young woman cardiac pain which cannot be referred 
of twentij-ftve. 

to any ot the varieties of neuralgia 

1 Vide Balfour, op. cit. second edition, 1882, pp. 273 and 306. 


just described, even althougli it occurs in a young 
person, and may be associated with more or less 
jactitation. Of this there could scarcely be a better 
example than the following case: In September 
1888, a young married woman was sent for my 
opinion, with the following history : " M. S., set. 
25 ; married five years ago ; has had two children, 
the last of them a month ago ; has hereditary pre- 
disposition to angina. About eight years ago she 
had diphtheria with pericarditis, from which she 
made a good recovery under the care of the late 
Dr. Kelburne King. She was married five years 
ago, became pregnant, and during the first six 
months she suffered much from attacks of syn- 
cope. She made a fair recovery from childbirth. 
During the last three and a half years she has 
suffered increasingly from syncopal attacks, pre- 
ceded by or accompanied with pains of an anginal 
character. She derives considerable benefit from 
nitrite of amyl inhalations, which cut the attack 
short. She was confined of her second child about 
a month ago, and recovered strength very slowly, 
until digitaline was administered, when she im- 
proved rapidly." I found Mrs. S.'s heart well 
contracted and slightly thumping in its action 
from three of Nativelle's granules having been 
taken daily for some time. She stated that her 
anginal attacks were always preceded by pallor 


of the face and fingers, that she could move 
about freely during the attack, and that it was 
always relieved by stimulants or by nitrite of 
amyl inhalations. The symptoms and history of 
this case showed it to be one in which the attacks 
were probably due to arterial spasm raising the 
blood pressure, and thus throwing an undue strain 
upon a feeble spansemic heart which had been 
somewhat dilated; the nervous phenomena being 
obviously due to the instability of the nervous 
system, an instability the result of imperfect nutri- 
tion. Evidently a case liable to be branded as a 
hysterical or pseudo-angina, but really a case of 
true angina occurring in a young neurotic female, 
from a curable cause, and with, therefore, a favour- 
able prognosis. Two years subsequently I enquired 
as to her progress, and received the following reply : 
" I may report favourably as to Mrs. S. The an- 
ginous character of her attacks gradually became 
less marked, and her general health much improved. 
She has since had another baby, making a good 

I have called this a case of true angina, and 
such it undoubtedly was, meaning by angina a pain 
of the heart induced by a call for increased exer- 
tion, as in this case from a reflex rise of blood 
pressure, as in others from mere bodily exertion. 

With this conception of angina, we can under- 


stand that it may vary much in degree. Probably 
the slightest possible form of it is the sharp pain 
„ . . that occasionally accompanies the aug- 

anginamay mentor action following an intermis- 
vary much. ^^^^^ ^^ ^ ^^^^,^ ^^^^i of tremor cordis 

in a spansemic heart. 

Apart from the trifling form just referred to, 
the pain of angina varies from a dull agonizing 
ache, to a feeling as if a mailed hand grasped the 
chest in the cardiac area and squirted through its 
fingers flashes of excruciating agony up to the left 
shoulder joint, sometimes into both shoulder joints, 
extending down to the elbow or along the ulnar 
nerve to the fourth and third fingers on the left or 
on both sides. Occasionally the pain shoots up the 
neck, generally on the left side ; or into the scrohi- 
culus cordis ; more rarely it shoots down the loins 
and legs. The sufferer has a feeling of choking, 
but the breathing is perfectly free, and is only 
restrained by the dread lest the slightest movement 
should precipitate the end which seems so terribly 
near. The countenance may be pinched, ghastly 
pale, and covered with beads of perspiration (^faoies 
Hippocratica). But often the face is quite un- 
changed, save only for an anxious, haggard expres- 
sion. In the angina that occasionally complicates 
aortic regurgitation or indicates substernal aneu- 
rism, as well as in that associated with other more 


curable cardiac affections, the pain is more acute, 

less oppressive and appalling, and it is sometimes 

conjoined with so much jactitation as to simulate 

a pure neurosis. 

The causes of angina may seem to be various, 

but they are all of a kind to depress the dynamic 

force of the nerve implicated, or of the 

, .,.,.,.. The cause of 

heart itseit, which is the automatic angina 

source of its own energy. Pressure on "^""oz/s some 

depressant of 

some 01 the nerves ot the cardiac or nervous or 
aortic plexus is not an infrequent cause cardzoc 

J. . rr... , energy. 

01 angina, ihis pressure may be pro- 
duced by a tumour, often a very small one ; by a 
small substernal aneurism, which usually escapes 
detection ; or by a dilated aorta, sometimes without, 
but more commonly associated with, regurgitation 
through the semi-lunar valves. 

One of the most common concomitants of angina 
is sclerosis of the coronary arteries ; indeed, so 
common is the conjunction that the arterial scle- 
rosis has often been looked upon as the cause of 
the angina. But coronary sclerosis is too often 
present, where there never has been any angina, 
to permit the concurrence being looked upon as 
anything more than accidental. Fatty degenera- 
tion of the myocardium is often found where 
angina has been present during life, and it too 
has been supposed to be a cause of the angina; 


but, like arterial sclerosis, fatty degeneration of 
the myocardium is very often found where there 
has been no antecedent angina. Like coronary 
sclerosis itself, therefore, fatty degeneration of the 
myocardium can only be regarded as a concomi- 
tant of angina, and not as a cause. On the other 
hand, fatty degeneration of the myocardium is due 
to faulty metabolism from an imperfect blood-sup- 
ply to the part affected ; an imperfect blood-supply 
is a common result of arterial sclerosis, and is in 
fact the connecting link between coronary scle- 
rosis and fatty myocardium. It is the one common 
factor these two conditions have — of 
ngina ^^ ^^^ -^ -^ ^ pgguit and of the other 

almost mvor- ' 

riabiy the a cause. And when we inquire into 

7ZlciZia. the matter, we find that an imperfect 
blood-supply is a factor common, not 
only to the conditions just referred to, but also to 
almost every condition of heart with which angina 
has ever been found associated. Among these we 
may reckon embolism and thrombosis of the cor- 
onary arteries — diminution of the calibre of these 
vessels at their origin at the root of the aorta, or 
in their course through the heart, by inflammatory, 
atheromatous, or syphilitic processes. On rare 
occasions the heart in late life becomes enlarged 
beyond the feeding powers of coronary arteries con- 
genitally deficient in size or in number, as happened 


in the case of Dr. Arnold.^ More commonly, simple 
dilatation and hypertrophy get in excess of the feed- 
ing powers of the ordinary coronaries, because of 
some failure in the quality of the nutriment supplied. 
A good deal has been said about tobacco and 
tea as causes of angina, especially by 
French writers, as if the nicotine and Tohacco, tea, 
theine produced it of themselves by a ZtanglZnu 
special act of poisoning. But angina voduce an- 

j. , , n I. gi^'^ only by 

from these causes, as well as from gas- enfeebling the 
trie derangements, is a rare accident, 'leart, and in- 
and never happens unless there has tive isehxmia. 
been some previous spangemia, and 
some slight dilatation of the heart. It accom- 
panies, or rather follows, some preceding irregu- 
larity of the heart's action ; this we know involves 

1 The size of the coronaries is quite disproportionate to the 
mass of muscle to be fed, so that the heart may he looked on as 
having an excessive supply of hlood compared with other mus- 
cles. — Odriozola, £tude sur le Oceur senile, Paris, 1888, p. 5. 
Dr. Arnold died at forty-seven of his first attack. "The heart 
was rather large. . . . The muscular structure of the heart 
was in every part remarkably thin, soft, and loose in its texture. 
The walls of the right ventricle were specially thin, in some 
parts not much thicker than the aorta. ... Its cavity was 
large. The walls of the left ventricle, too, were much thinner 
and softer than natural, and the muscular fibres of the heait 
generally were pale and brown. . . . There was but one cor- 
onary artery, and, considering the size of the heart, it appeared 
to be of small dimensions." — Latham, Diseases of the Heart, 
London, 1846, Vol. ii., p. 377. 


lessening of the ventricular output, with conse- 
quent residual accumulation and ventricular dila- 
tation (vide antea, p. 41). To empty the ventricle 
in this condition the augmentor nerve is called 
into play, and this call for extra exertion is the 
incitation to angina. Not because tobacco and tea 
are poisons specially incentive to angina, but be- 
cause their abuse has so lowered the health and 
impoverished the blood as to enfeeble the myocar- 
dium and induce a relative ischsemia, an ischaemia 
of quality though not of quantity. Spaneemic 
blood involves imperfect nutrition, and as the 
energy of the heart depends upon the perfection 
of its metabolism, long continuance of imperfect 
nutrition implies a commensurate loss of cardiac 
energy.i After middle life this is always a serious 
matter, and even in youth it is not devoid of dan- 
ger, and raay precipitate a fatal issue. 

The vigour of a muscle may vary from nothing 

to a maximum, and depends upon the 

imperfect perfection of its metabolism. An or- 

cardiac dinary skeletal muscle only possesses 


irritability towards stimuli ; but the 

heart has not only the power of originating spon- 
taneous rhythmic movements, but is also able to 

^ Von Bezold, Untersuchungen aus dem physiologischen La- 
boratorium in Wurzburg, Leipzig, 1867 ; Erster Theil, S. 
279, etc. 


store a reserve of energy so great that, in some 

animals, these spontaneous movements go on for 

hours after the heart has been separated from the 

body. It is evident, therefore, that the metabolism 

of the heart is of a very much higher order than 

that of the skeletal muscles, and is all the more 

readily affected injuriously by any changes in the 

quantity or quality of the blood which furnishes 

its basis.^ The large reserve of energy with which 

the heart starts on its extra-uterine life, and which 

is always maintained during healthy life, enables 

it at any age long to resist hurtful influences of 

this character, but in time they tell. 

When a bad bout of irregularity or intermission, 

induced by mental emotion or any other cause, or 

when such an increase of muscular exertion as is 

involved in going up a stair, or any acclivity, or 

when any sudden rise of blood pressure, from 

reflex causes, calls for increased action 

in a heart with its energy impaired <^f'>^^^f«-fit 

°-' ^ of angina. 

by malnutrition from long-continued 
spansemia, by positive obstruction to the coronary 
circulation, or, as is more frequently the case, by 
a combination of both, the response may be so 
imperfect that the function of the augmentor 
nerve is sensibly impeded. The call for increased 
katabolic action is at once followed by sudden 
1 Foster, op. cit., p. 344. 


exhaustion, and this is revealed as an agonizing 

pain beneath the sternum, that shoots along some 

or all of those sensitive spinal nerves with which 

the sympathetic or katabolic nerve is embryologi- 

cally connected.^ 

Like other neuralgise, angina originates in a 

lowering of the function of the nerve affected. 

Usually the nerve function is lowered by 

long-continued imperfect nutrition, occasionally 

brought to a climax by some positive cause of 

ischsemia, as vascular spasm, etc. More rarely 

the nerve function is depressed by 

well known to actual pressure upon some of the 

be a cause of branches of the cardiac or aortic plex- 
severepain. , . ^ 

uses, by an aneurism, a tumour, or a 

dilated aorta. Those conditions which do not 

necessarily involve ischsemia have always, in my 

experience, been accompanied by a less severe, 

though not always a less dangerous, form of 


I suppose Jenner was the first to point out the 

probable connection between ischsemia and angina. 

He does not explicitly state this connection, but 

he certainly implies it in saying, " The importance 

of the coronary arteries, and how much the heart 

must suffer from their not being able to fulfil their 

1 Vide Gaskell, TJie Journal of Physiology, Vol. vii., p. 1, 
and especially, pp. 41 and 46. 


function, I need not enlarge upon." ^ As Kreysig 
has said, "The word ischeemia was not then in- 
Vented, but tlie thing itself was well known." ^ 
That ischsemia does give rise to pain, even of the 
most atrocious character, is sufficiently attested 
by the agony that attends compression of an artery 
for aneurism, especially at the moment the vessel 
becomes completely occluded; the pains, arising 
from a similar cause, that precede the appearance 
of gangrenous patches in a limb affected with 
senile gangrene ; and those which precede, accom- 
pany, and follow attacks of local asphyxia (Ray- 
naud's disease). There is every reason to suppose 
that the arterial spasm, which is so evidently the 
cause of local asphyxia, and which takes so promi- 
nent a share in the production of an attack of 
angina vaso-motoria, occasionally invades the heart 
either as part of a general condition, or it may be 
as a distinctly local affection, and that this is a 
very possible cause of those anginal attacks where 
no other seems obvious. For myself y;,, ,„„.,j ,,„.. 
I can, however, say that I have never ous forms of 
yet seen a case of true cardiac angina ^ZTinZlich 
in which I have been unable to detect the least is to 
some of the physical signs of dilata- 

1 Letter to Heberden in 1778. Vide Baron's Life ofjenner, 
Vol. i., p. 40. 

2 KranJcheiten des Herzens, Berlin, 1816, Bd. ii., S. 544. 


tion of the heart. It may, indeed, be accepted 
as a fact, to which I know of no exceptions, 
that the less there seems to be the matter with 
the heart the more grave is the prognosis, if the 
anginous attacks are at all serious. 

In angina pectoris, as in other neuralgiee, we 
have the presence of a permanent lesion coupled 
with only occasional attacks. For these attacks 
there is always some more or less obvious cause. 
Parry said long ago that the symptoms of angina 
arise from a temporary increase of weakness in an 
organ already weakened.^ Doubtless this is the 
case when spasm affects the coronaries and dimin- 
ishes the blood-supply of a heart already suffering 
from malnutrition. As a rule, however, it is quite 
the other way; it is not the weakness of the 
heart, but the work it has to do, that is in- 
creased, and the work may be increased in various 

Exertion is the commonest cause of increased 

cardiac action, because the metabolism of the heart 

and other muscles, when in action. 
Various ways 
in which an- requires more frequent flushing with 

gmamaybe blood than when they are quiescent, 

brought about. 

especially if the blood is defective in 
oxygen or in nutritive material. And exertion 
after a meal is more apt to induce a paroxysm 
^ Quoted by Stokes, op. cit., p. 486. 


than when the stomach is empty ; first, because 

a full stomach impedes and oppresses 

the heart; and second, because shortly ^"^J""/™™ 

■> exertion. 
after a meal the vessels are fuller 

and the blood pressure somewhat raised. 

Any overwhelming emotion may prove suddenly 

fatal by its action on the heart, and when sudden 

death has been preceded by repeated 

attacks of angina, as in the case of ^"^f""/™'" 

° emotion. 

John Hunter, it has been assumed that 
death has been due to this cause. And this as- 
sumption is probably correct though the fatal 
seizure is often an angina sine doloi'e, an instanta- 
neous death without a cry or any indication of 
suffering. In such cases the heart may be sud- 
denly arrested in diastole through vagus action, 
an arrest which the katabolic action of the aug- 
mentor nerve fails to overcome; or the emotion 
may induce irregularity with residual accumula- 
tion, which the augmentor nerve fails to expel. 
In the one case death is instantaneous, as in so 
many recorded instances (vide note, p. 31, antea') ; 
in the other case, as in that of John Hunter, there 
may be time to retire to an adjoining apartment 
before the heart actually fails and death ensues. 
In both forms death arises from failure of kata- 
bolic action, and both may, therefore, be claimed 
as deaths from angina. 


Exposure to cold, especially to a cold wind strik- 
ing the chest, is a very common cause of angina ; 
the attacks thus brought on are, how- 

Anginafrom ^^^^ ^^ ^^j , ^ ^^ almost to be 

cola. ' o 

regarded as mere neuralgia — nerve 
pain • — from cold, were it not that relief so immedi- 
ately follows the use of nitro-glycerine — or some 
similar remedy — as to make it clear that the chill- 
ing of the surface had sufficed to contract the super- 
ficial vessels, and so raised the blood pressure as 
to induce a paroxysm of angina. 

Occasionally the spasm of the vessels arises not 
from cold, but from some internal cause; some 

organic derangement — stomach, liver, 

Vaso-motor ^^ other orsfan ; or from some impurity 
angina. ° jr ./ 

of the blood ; and then we have cold- 
ness and numbness of one or more of the extremi- 
ties, followed immediately by anginous pain.^ In 
one such patient the coldness and numbness at 
first affected the right arm alone, and his heart was 
fairly good, but this organ dilated considerably 
before his death, which happened suddenly about 
two years after he was first seen. 

Pain, though so usual a concomitant of an attack 
that angina cannot even be thought of without 

1 Landois, Lehrbuch der Physiologie des Menschen, 7te auf- 
lage, Wieii u. Leipzig, 1891, p. 817. Also Eulenberg, Ziems- 
sens Cyclopedia, Vol. xiv., p. 48. 


bringing up with it the idea of intense agony, yet 
forms no essential part of the disease, and it is no 
misnomer to speak of angina sine dolore} Most if 
not all fatal cases are of this character ; so far as 
my experience goes, by far the greater number of 
fatal seizures have been apparently painless. 

In ordinary cases of painless angina there is 
breathlessness, but no pain, and the attack gets the 
name of cardiac asthma.^ A nocturnal attack of 
cardiac asthma is often the beginning of the end, the 
earliest indication that the senile heart 
has become seriously dilated. Now asthma a 
and then ordinary attacks of painful vaso-motor 

J. angina sine 

angina cease, and towards the close oi Colore, 
life the patient suffers only from fits of 
breathlessness. At other times the attacks of pain 
and of breathlessness alternate. And at still other 
times the pain, with which the attack commenced, 
passes off and leaves behind it a cardiac asthma as a 
continuance of the seizure. I myself have assisted 
at the development of a case of the last mentioned 

1 Vide Gairdner in Reynold's System of Medicine, Vol. iv., 
p. 566. 

2 Stokes says : " Well-marked instances of the affection as 
described by Latham are rarely met with, and the same may 
be said of the purely nervous oases noticed by Lsennec. I have 
never seen either of these forms. The disease which in this 
country (Ireland) most often gets the name of angina pectoris 
might be more properly designated cardiac asthma." — Op. cit., 
p. 488, 


variety. A man aged fifty-seven had suffered 

from angina occasionally for years ; the 
Gase of trans- i i i 

ferenceof Seizure was brought on by exertion or 

pressure from \yj emotion, and the pain shot from 

tTh& QiOT'tic to 

thepuimo- mid-sternum through to the back and 
nary vascular (Jqwu the left arm, occasionally down 
the left leg, and sometimes down the 
right arm also. The heart had a feeble impulse 
and was slightly irregular, the aortic second was 
accentuated, and the first sound over the apex 
was blunt. The radial pulse was tense. Signs 
which indicated a high blood pressure and a dilat- 
able and probably somewhat dilated heart. While 
I was listening to his heart sounds, nervous excite- 
ment brought on an attack of angina, pain accom- 
panied by a feeling of suffocation. Gradually, as I 
listened, a distinct auricular murmur developed, 
and pari passu with this the pulmonary second 
became not only markedly accentuated, but also 
acquired a booming quality. Evidently residual 
accumulation, due to irregular and imperfect ven- 
tricular contraction, had overdistended the ventricle 
and promoted regurgitation through the mitral 
opening, causing considerable pulmonary conges- 
tion. From the same cause the radial pulse, which 
had been firm and tense, became gradually small 
and feeble. Obviously there had been a transfer- 
ence of the blood pressure from the aortic to the 


pulmonary system, and with that an increase of 
the breathlessness, amounting to a slight attack 
of cardiac asthma. 

No doubt ordinary attacks of cardiac asthma of 
the kind I now speak of have all a similar origin ; 
irregular or imperfect cardiac action, not marked 
enough to induce anginous pain, yet avails to 
induce residual accumulation and mitral regurgi- 
tation in a dilated or dilatable heart, and so an 
attack that begins as a reflex spasm of the systemic 
arterioles ends in pulmonary congestion and cardiac 

In one old lady the illness commenced with an 
attack of pain in the scrobiculus cordis simulating 
the passage of a gallstone ; ^ her subsequent attacks 
were simply fits of intense breathlessness without 
pain, accompanied by a feeble, wobbling heart-beat, 
and a hard, wiry pulse of high tension. As this 
tension relaxed and the pulse became soft, the attack 
passed away. After a very severe attack one even- 
ing, which lasted over an hour, she fell asleep, 
woke in the early morning with a slight attack 

I " It occasionally happens that the very intense and sickening 
pain of "biliary calculus presents a degree of resemblance to 
angina in its accessories ; and the author has even observed 
cases in which the diagnosis remained doubtful until the yellow 
tinge of the conjunctiva, appearing after an interval of hours, 
relieved the apprehensions of the physician." — Gairdner, loo. 
cit; p. 546. 


of Cheyne-Stokes respiration, and passed quietly 


Many of the victims of fatal angina pass away 

unobserved during the night ; but not a few have 

had Ishmael's privilege of dying in the presence 

of their brethren, sometimes suddenly 

aZlnal!Zer. and without warning, while at other 

ally painless, times death has been preceded by a 

asystole may longer or shorter period of conscious 

be sudden or sinking.^ So far as my own experi- 
ingravescent. i i- i i i 

ence goes, by tar the larger number 

of fatal seizures have been apparently painless. 
Death has occurred in those fatal cases precisely 
as it does in animals which have had their coro- 
nary arteries artificially blocked ; ^ sometimes the 
heart has failed suddenly ; at other times complete 

1 In one recorded case this conscious sinking occupied quite 
half an hour. Vide Balfour, op. cit., p. 305. 

2 Vide Panum, Virchow's Archiv, Bd. xxv., 1862, S. 308, 
etc. ; Von Bezold, Tfntersuchungen aus dem physiologischen 
Lahoratorium in Wurzburg, erster Theil, 1867, S. 256, etc. ; 
and See, Comptes Bendus, Tome xcii., 1881, p. 88. See found 
that section of the vagus did not in any way modify the phe- 
nomena produced hy occlusion of the coronaries, and also that 
stimulation of the vagus had no effect whatever on an ischsemic 
heart. Complete ischsemia is not always immediately fatal, 
because of the enormous reserve of energy that the heart pos- 
sesses, which it takes some time to exhaust. But a long con- 
tinuance of imperfect nutrition modifies this reserve of energy 
in a most important manner, diminishing it remarkably. — Von 
Bezold, loc. cit., S. 279. 


failure has been preceded by a longer or shorter 
period of ingravescent asystole (more or less con- 
scious sinking), — the longer or shorter time occu- 
pied in dying evidently depending upon, first, the 
degree of ischsemia, actual or relative, present in 
each case, and, second, the length of time during 
which comparative ischsemia has already persisted, 
and the consequent amount of exhaustion which 
the cardiac energy has already sustained. The 
pre-existing nutritional vigour of the heart, and 
the nature of the exciting cause, have all some- 
what to say in regard to the actual mode of death. 
One gentleman, over eighty years of age, who had 
long suffered from angina, took his seat at a public 
meeting, and, without a sigh, sank down dead. I 
have just mentioned (p. 138). one case in which 
ingravescent asystole occupied fully half an hour. 
When I entered this patient's bedroom, he said 
to me, "Doctor, this is very different from any- 
thing I have had before," and he died quietly, 
after drinking about half a glass of brandy given 
him in the hope of stimulating his heart to more 
vigorous contraction. A few years ago I saw an 
old gentleman for severe angina. Some weeks 
subsequently he assisted home a friend who had 
met with a slight accident; this made him feel 
very unwell, but he struggled to reach his own 
home, took to bed, and died within twelve hours, 


never having recovered from his exhaustion. An- 
other old gentleman, long a sufferer from angina, 
but who for the last two years of his life had been 
free from pain, a week before he died had what was 
called a faint, really an attack of cardiac failure, — 
an angina sine dolore. During the week for which 
his life was spun out by the judicious use of stim- 
ulants and a careful avoidance of the most trifling 
exertion, he had several trifling attacks of a simi- 
lar character. The final seizure was absolutely 
painless ; life ceased because the heart failed to 

Again, during last winter (1892-93) there was 
a man in Chalmers Hospital suffering from aortic 
regurgitation, accompanied with attacks of angina, 
with a tense pulse and high blood pressure, evi- 
dently of reflex origin and chiefly occurring at 
night. After much suffering, this man's strength 
at last broke down ; but he took many weeks to 
die, and his death was a most notable example of 
ingravescent asystole (vide antea, p. 80). The 
degree in which the cardiac energy has been pre- 
viously exhausted by malnutrition — imperfect 
metabolism — regulates the rate at which asystole 
progresses. Long - continued malnutrition of a 
serious kind, rapid failure at the last; less serious 
interference with the metabolism of the heart, in- 
volves a slower process of dying. At times we 


can predict the near approach of death, but in the 
greater number this is impossible, and chiefly for 
this reason, that, even when the cardiac output is 
greatly diminished, the blood pressure does not 
fall fari passu, but for a time remains normal till 
the fatal limit is reached, when the pressure sud- 
denly falls, and death ensues.^ 

Death from angina is thus not always instanta- 
neous, nor is angina alwa3'-s fatal. Angina may 
even be recovered from, sometimes 

Elements of 

perfectly, for when the cause is reme- prognosis in 

diable, the angina is also curable. At ""ff*"" 
. T . . , , pectoris. 

other times the pain is removed, but 

the disease progresses, and after a longer or 

shorter period free from suffering, or with only 

occasional attacks of cardiac asthma, the patient 

at last succumbs, dying of angina, no doubt, sed 

sine dolore. 

In endeavouring to get a basis for a prognosis in 
any case presenting symptoms indicative of angina, 
the first point to ascertain is whether we are deal- 
ing with a true angina, or merely with one or 
other of the varieties of neuralgia referred to at 
page 117. 

In the absence of any opportunity of observing 
a seizure, there may occasionally be some difficulty 

1 Vide Roy and Adami, British Medical Journal, December 
15, 1888, p. 4 of the reprint. 


in deciding this matter. Any indication, however 
slight, of dilatation of the heart must be looked 
upon as a point in favour of the reality of the 
angina, and this at any age. In youth the proba- 
bility is greatly in favour of this dilatation de- 
pending on curable spanaemia, and therefore of the 
angina itself being curable. After middle life we 
may still have to deal with a curable spanaemia, 
though the dilatation in no case depends solely on 
this ; and the next point to determine is, have we 
here simple senile dilatation, or are the coronaries 
also in any way obstructed? Atheroma of the 
external arteries affords a certain presumption in 
favour of the coronaries being also atheromatous ; 
but even if they are, it is obstruction and not 
atheroma that induces ischsemia, and the question 
at issue can only be decided by the results of 

On the other hand, if there be no indication of 
cardiac dilatation, — which is but seldom the case, 
— an anxious, haggard expression unmistakably 
indicates great suffering and a serious disease, 
while a countenance free from distress or anxiety 
is an equally certain indication that, whatever may 
be wrong, we have not to deal with a serious 
angina. But though not due to angina, substernal 
pain may be quite as dangerous : it may be due to 
a small aneurism impossible to detect. Such cases 


are great sources of anxiety to the physician, and ' 
too great caution cannot be exercised in giving 
any decided opinion in regard to them. 

The large reserve of energy with which every 
heart starts in life enables it long to resist the 
many injurious influences to which it may be ex- 
posed ; hence, considerable enlargement is quite 
consistent with perfect freedom from angina, if 
the arteries are pervious and the blood of good 
quality ; yet such a heart has its metabolism easily 
upset, and comparatively slight causes suffice to 
induce an anginous seizure. There is little won- 
der, then, that so many senile hearts are subject to 
angina ; the wonder is rather the other way, — 
that there are, comparatively, so few hearts, even 
of those showing decided signs and symptoms of 
cardiac degeneration, that are affected by this com- 
plaint. Statistics are proverbially uncertain, and 
the character of any man's experience depends 
very much on where he has obtained it, so I give 
mine only for what it may be worth, without 
claiming for it any special accuracy in regard to 
any one particular. 

Confining myself solely to those patients who 
consulted me at my own house, during the ten 
years 1879-89, I find that I have notes of 1173 
cases of various affections of the heart and aorta. 
Of these, 581 were senile hearts, 270 were young 


spangemic hearts, and only 57 were cases of heart 
affection distinctly traceable to rheu- 
poruonor' i^^tism. Of the 681 senile hearts, 98, 
senile to other or rather over one-sixth, made a prom- 
heaZ'Indof i^^ent Complaint of angina. Of these, 
angina to the 17, or nearly one-sixth, were females, — 

senile hearts. • i i n i j.- ii_ 

a considerably larger proportion than 
the 8 females out of 88 cases collected by Sir John 
Forbes, but the number is still sufficiently small 
to make it probable that Forbes is right in say- 
ing that angina is more common in men than in 
women ; a proposition which few will be inclined 
to deny.i 

Of the 98 cases of angina, 15 are certainly known 
to have died, without having gained anything from 
treatment beyond palliation of the symptoms ; and 
17 are known to have got entirely free of their 
painful seizures. Of these 17, 13 are still alive 
in apparently excellent health, and 4 have died 
after a longer or shorter period of complete free- 
dom from pain. 

One of these patients was for four years and a 
half completely free from pain ; during this period 

1 Cyclopedia of Practical Medicine, Vol. i., p. 83. But 
Forbes adds : "Of milder cases, a very considerable proportion, 
perhaps an equal proportion, are met with in females, and at 
an earlier period of life. This at least is the result of our own 
experience ; and the same opinion is entertained by writers of 
great authority." — Loc. cit. 


he progressed from sixty-nine to seventy-three 

years of age, and was able to carry on 

his business, attending markets in all -^"««*''«'«''« 
° cases. 

parts of the country. At last, after 
attending market in the country town in which he 
lived, and having transacted business in appar- 
ently perfect health, he returned home, sat down, 
and without a complaint quietly departed. When 
first seen, this gentleman had suffered from angina 
for eight weeks, and attacks came on whenever he 
attempted to go up any ascent, and the pain ex- 
tended into both arms, but chiefly into the right 
one. For years he had been breathless ; his ar- 
teries were all atheromatous, hard, and tortuous ; 
his heart was dilated, with a feeble impulse, and 
there was a loud systolic murmur in all the cardiac 
areas. Under treatment, the pain entirely ceased 
in a few months, the heart's impulse became much 
stronger, the murmurs less distinct, and he de- 
clared he was as able as ever to go up hills or 
stairs. About seven months before his death he 
had a severe fall, and was never so well after- 
wards. On the day of his death he had been 
about his business all day, apparently as well as 
ever he was; he went out again in the evening, 
returned about half-past seven, sat down, and 
quietly died. After death his face was pale, with 
a most placid expression, his pupils were both nat- 


ural. There was no post-mortem examination of 
the body. 

A second case was that of an old gentleman, 
between seventy and eighty years of age, who was 
two years under treatment before he got rid of his 
pain. The remedies employed gave gre'at relief, 
but the pain continued to recur upon exertion, and 
sometimes in bed if his stomach was flatulent, for 
quite two years ; after this he had no more attacks 
of pain. When first seen this patient had a feeble 
impulse, and a loud systolic murmur in all the 
cardiac areas ; when last seen, just a week before 
his death, his apex-beat was fii'm, the systolic 
murmur loud, and the heart's action intermittent 
and irregular. His arteries were very hard from 
the first. About four years after he was first seen 
— two years after the cessation of pain — he had 
what was described as a bad faint ; two days subse- 
quently he had another slighter attack of a similar 
character, but no pain ; and just one week after- 
wards he died quietly and suddenly one forenoon, 
sitting in his chair. 

The third case was that of a fresh-looking man 
of sixty-one, who had firm arteries with high blood 
pressure, a large, dilated, and somewhat hyper- 
trophied heart, with considerable palpitation and 
irregularity of action. He had severe anginous 
pain across his chest upon exertion, extending 


down the right arm. The urine was of low spe- 
cific gravity, — renal inadequacy, — and there was 
an occasional trace of albumin. He had also long 
suffered from an irritable bladder and an enlarged 
prostate gland. The angina was speedily relieved 
by treatment ; but about four months subsequently 
he had an attack of pneumonia of no great severity, 
and during convalescence he died somewhat sud- 
denly from ursemic sinking. 

The fourth case was that of an old gentleman 
between seventy and eighty, who, after nearly 
ten years' relief from pain, and of really excellent 
health, was suddenly seized during the night with 
an attack of cardiac asthma and died in about half 
an hour. 

Of the other thirteen who got rid of their attacks 
of pain, some have been free for quite ten years, 
others for varying periods down to five years. 
Most of them I see occasionally ; the rest I hear of, 
and I know them to be well, each with a good firm 
heart-beat and no pain on exertion ; even breath- 
lessness is not much complained of, though where 
murmurs did exist they still persist. The great 
difference between their past and present is that 
whereas their hearts were formerly feeble and ill 
fed, they are now strong and well fed. To keep 
them in this condition they require constant care, 
watching, and treatment, and in the face of advanc- 


ing age none of these can be long pretermitted 
without risk of a serious relapse. 

Of the fatal cases to whom treatment gave only 
temporary relief, two were little over middle life ; 
both were busy men. In the first of these the apex 
beat below the left nipple ; the first sound was almost 
absent, quite faint and impure ; the aortic second 
was accentuated ; there was no distinct murmur 
anywhere detectable ; the fits of angina were very 
severe and easily brought on. I saw this patient 
in one of his attacks, and formed a most serious 
prognosis from the severity of the pain, the com- 
parative youth of the patient, and the little that 
was to be found wrong with his heart. He dropped 
down dead in his own hall about a month after I 
saw him. 

The second patient had a slight systolic murmur 
in the mitral area ; the apex beat just inside the 
left nipple ; the aortic second was accentuated. 
The fits of angina were said to be very severe, but 
I had no opportunity of seeing one. I gave an 
unfavourable prognosis for reasons similar to those 
given in the former case. Three months subse- 
quently this patient was found dead in his office. 

Three patients had serious illness connected 
with the heart for some weeks before death. One 
of these was never well after his first attack of 
angina ; he had a large, dilated heart, and died 


within two years. The other two were country 
lawyers, who carried on their arduous business, 
one of them for ten and the other for seven years, 
subsequent to their first attack of angina ; ^ both 
died after short illnesses following overexertion in 
the course of business. 

One clergyman, after suffering for about seven 
years from a dilated heart with angina on exertion, 
hurried to catch a train at a country station, and 
died resting in a chair on which he sat down 
exhausted when he reached his goal. 

Another clergyman had been out for a drive one 
bleak November day ; on coming home he sat down 
by the fire, complaining of cold, and slipped from 
his seat dead. He was sixty-five years of age, and 
had a large, dilated heart, with a shrill systolic 
murmur in all the cardiac areas. He died within 
a month of being seen, having been much relieved 
by treatment. 

A third clergyman (each of these was of a differ- 
ent persuasion) wrote me as follows a few weeks 
before his sudden death : " I don't know whether 

1 As I was writing this, the son of one of these lawyers, a 
man thirty-eight years of age, called, complaining of angl- 
nous pains, on exertion, of short duration and not severe. His 
heart was weak, its sounds parchmenty in character, the blood 
spansemic from imperfect recovery from an attack of drain- 
poisoning a year ago. He recognized the pain as similar to 
what his father had suffered from. He died within two years. 


you will remember my consulting you about a year 
ago. . . . As long as I keep still I have no discom- 
fort, but very frequently, though not always, if I 
walk fifty or sixty yards I am seized with the most 
painful spasms, not in my heart, but in the pit of 
the stomach. If I stand up, the pain comes on ; 
even putting off or on my clothes excites it. Yes- 
terday I went to my garden, a distance of less than 
one hundred yards; I had severe pain, and on 
coming home our local medical man, who happened 
to be in the house, found my pulse to be inter- 
mittent; this must have come on recently, as he 
never observed it before. I am seventy-one years 
of age, and with the exception of this pain I am in 
perfect health, and feel as strong and well as I was 
twenty years ago. As I cannot walk, I ride or 
drive, and I can do both in moderation, provided 
I enter my carriage or mount my horse slowly, but 
any sudden or quick movement brings on discom- 
fort. Sometimes I am for a week quite well, and 
then without any cause which I can trace I am 
suddenly plunged into the most extreme discomfort. 
A brother of mine suffered for some time from 
exactly the same symptoms ; he was told he was 
suffering from long-standing heart complaint. For 
the last three years all his symptoms have dis- 
appeared, and he is now quite well." This old 
clergyman had hard, atheromatous arteries, a large. 


dilated heart, with a systolic murmur in all the 
areas, and the aortic second so feeble as to be quite 
inaudible. No diastolic murmur was to be heard. 
He died quite suddenly a few weeks after writing 
the foregoing letter; no treatment gave him any 

Other four angina patients of the ninety-eight 
referred to also died suddenly. One of these was 
a case of free aortic regurgitation, with a large 
heart ; the other three were cases of dilated heart, 
two of them with a blunt first, an accentuated 
aortic second, and no murmur; the fourth had a 
large, dilated heart, an accentuated aortic sec- 
ond, and a systolic murmur in all the areas. 
He was fifty-eight years of age, and treatment 
gave him great relief, but he died about four 
months after being first seen. One morning after 
breakfast he attempted to raise himself in bed, gave 
a few gasps, and died. I have no particulars as 
to the mode of death in the three preceding 

The following case is very instructive from more 
than one point of view. On the 21st of January, 
1880, I was asked to see a gentleman suffering 
from angina. I found him to be a well-preserved 
man of sixty-eight, suffering so much that the 
exertion of walking even ten yards, or taking off 
or putting on his clothes, sufficed to bring on an 


attack of pain, distressing enough, but not of great 
severity. His heart was slightly enlarged; the 
apex beat in the fifth interspace almost directly 
below the left nipple ; the first sound was blunt, 
the second accentuated, the arteries hard and 
atheromatous. I prescribed for him, and recom- 
mended him to get out of business, and if possible 
into a warmer climate. As he had already suffered 
much from physicians, I gave him, at his own 
request, the following letter, to show to any physi- 
cian who might be called in, the view taken of his 
case, and the lines on which it was desired to have 
the treatment carried out. 

Janijaey 21st, 1880. 

Dear Sir : I shall group what I have to say under three 

heads : — 

1. The nature of your disease and its cause ; 

2. The treatment, medical and general ; and 

3. The results to be expected from that treatment. 

1. The cause of your disease is primarily a loss of elastic- 
ity of the arteries ; by this a greater strain is thrown upon 
the heart than usual. The result of this extra strain is, in 
your case, a slight enlargement of the heart — dilatation with 
compensatory hypertrophy. In your case the hypertrophy 
is somewhat insufficient, and the result is that when your 
heart is called upon for any unusual exertion, either by emo- 
tion or bodily exercise, it becomes pained, and the pain 
shoots along the course of various nerves connected with 
those of the heart, and thus gets referred to various other 
parts, as the arms or stomach, after a fashion with which 


medical men are only too well acquainted. In its essence it 
is an angina pectoris, not associated with a lesion of any 
valve, though I quite believe that the signs of mitral regur- 
gitation may sometimes be present. 

2. The medical part of the treatment resolves itself into 
means to relieve the pain when it occurs ; and, secondly, the 
use of remedies to improve the condition of the heart, and 
thus lessen the frequency of the attacks. These prescrip- 
tions will be found on a separate paper, and on it the medi- 
cal man, whom you must always send for at once on the 
occurrence of any seizure, will also find noted down sugges- 
tions as to certain supplementary measures which may be 
employed if the attack does not quickly yield to the means 
first employed. The general treatment must consist in a per- 
sistent avoidance of all bodily or mental excitement. You 
should, therefore, go about on foot as little as possible ; at 
present drive only. Shun all public meetings and worry of 
every kind. To gain this complete rest of body and mind, 
as well as to escape our often severe cold, which for you is not 
devoid of danger, I would strongly recommend you to start 
at once for the south of England at least, and if at all able, 
for the south of France. I have no doubt that you will 
benefit greatly by the change, and I think you will manage 
it comfortably, taking the journey by easy stages. 

3. The amount of benefit you are to expect from treatment 
depends upon conditions as yet unknown to me, but which 
will reveal themselves by and by. What I aim at is to put 
on the drag, so as to stop you from going down hill so rapidly 
as you have been doing. If your heart muscle is as sound 
as I believe it to be, the treatment may result in completely 
stopping the pain ; more probably, from the long time the 
pain has already troubled you, it will only come seldomer and 
be less severe. The causes of your ailment are incurable ; we 
can only mitigate the results. Sometimes the relief obtained 
is so great as to simulate a perfect cure, and this is what we 
aim at. I am, etc. 


The following December I wrote the patient's 
doctor to enquire as to his condition, and received 
the following reply : " I saw Mr. B. about two 
months ago, and found him in excellent health. 
I believe he is at business every day, and able for 
a good day's work. After you saw him with me 
in spring he went to Bournemouth, with which he 
was delighted. He stayed there three months, and 
came home in June immensely improved in every 
way. No return of the angina pectoris, nor any 
tendency thereto, since you last saw him. July 
and August he spent at Crieff, and thought this 
also helped him greatly. When I examined him 
in June, there was still evidence of the dilatation 
of the heart, but I could make out no murmur. 
His breathing power was also much improved ; he 
could walk much farther, without ever requiring to 
stop as formerly." 

Early in the following March Mr. B. paid me 
another visit ; he assured me that so far as he could 
judge he was as well as ever he was, and that he 
had only called to obtain my sanction to his mar- 
riage, as he thought an agreeable companion would 
greatly conduce to his comfort and happiness. 

I found the heart's impulse much improved in 
strength, otherwise the condition of the heart was 
as formerly, and my sanction to his marriage was 
given along with some sage advice. After this 


Mr. B. continued in the enjoyment of apparently 
perfect health for about two years. Then his part- 
ner in business died rather suddenly, and as this 
partner had for some years taken the larger share 
in conducting their very extensive business, the 
whole of this, with all the correspondence, was sud- 
denly thrown upon Mr. B. The result was a com- 
plete breakdown; the work and worry were too 
much for his heart ; this organ rapidly dilated, it 
developed a loud systolic murmur in all the areas, 
its action became embarrassed, very considerable 
general dropsy set in, and the case looked most 
serious. Fortunately, the recuperative power of 
the heart was not lost ; it responded well to treat- 
ment, and a few weeks of perfect rest restored 
Mr. B. again apparently to his former state. His 
health seemed quite re-established, he suffered no 
more from his heart, and he was able to go about 
and enjoy himself, though debarred from any 
longer taking an active share in business. Two 
years more passed away, and again I saw Mr. B., 
this time for a slight paralysis affecting the left 
arm, apparently due to some cortical thrombosis 
or small embolism. This paralysis came on with 
giddiness as he was leaving church one Sunday 
afternoon; it speedily passed away, and left him 
not a whit the worse. Six months afterwards he 
died from pneumonia. Being from home, I did not 


see him upon this occasion, but I understand that 
his damaged heart undoubtedly hastened his end. 
It is the rarest thing in the world — if indeed it 
ever happens — for a man over sixty, with a di- 
lated heart, to recover from pneumonia. Even if 
he recovers from the primary attack, the exhaus- 
tion following it initiates the beginning of the end, 
which is no long time in following. 



Latham has finely said that the clinical history 
of diseases of the heart is but the history of " those 
prior and accompanying conditions in the life and 
health of the patient, which were found variously 
leading to and variously promoting and causing 
them ; as well as all those subsequent conditions 
in the life and health of the patient variously 
springing from them and variously promoted and 
caused hy them." And Latham adds that the 
treatment of such diseases is but the employment 
of "means of influencing those same conditions 
and of influencing them for good."^ 

These statements — so true of all cardiac dis- 
eases — find their pre-eminent application in senile 
affections of the heart. For the clinical history 
of these affections is not the mere story of the 
past few weeks, but comprises the life-history of 

1 Latham, op. cit.. Vol. ii., p. 360. 


the patient from his cradle to his grave, and often 

includes that of his forefathers also. 
The story of x t- 

senile cardiac They form part and parcel of the pa- 
disease com- plant's development, and are the natural 

prehends the '■ 

whole life- result of prematurity, or of excess, in 
story of the ^.j^^g^ changes affecting the arterial tis- 

patientfrom ° ° _ • 

his cradle to sue which Wait upon advancing years, 

his grave. ^^^^ which in their turn variously 
modify every subsequent condition in life. These 
tissue changes commence long previous to the time 
when either symptoms or organic changes force 
themselves upon the attention of patient or physi- 
cian. During all this time they have been slowly 
but persistently exerting a modifying influence, not 
alone upon any one organ of the body, but on every 
tissue of which the body is composed, as well as 
on every function which its organs discharge. 

The arterial dilatation, already referred to, which 
results from the loss of elasticity, coupled with 
lessening of the capillary area from obsolescence 
of many of these vessels, gradually induces another 
change in the circulatory system too often forgotten 
or overlooked, but which is yet a factor in every 
function of our future life important enough to 
demand our most serious attention. 

Up to the completion of puberty the pulmonary 
artery is larger than the ascending aorta; with 
the advance of maturer years, and the coincident 


changes in the circulatory system, a change takes 

place in the relative size of these ves- 

1 1 rT-,1 _ec J !■ , 1 • 1 Change in the 

sels.^ ihe eftects of this change are relative size of 

of the greatest importance. So long thepuimonary 

OiVt&py at id tlip 

as the pulmonary artery remained the aorta takes 
larger of the two, the blood within the ^^"^^^ «*""* 
pulmonary circulation was kept at a 
high pressure, and this notwithstanding a free and 
unembarrassed egress into the left heart, and so 
onwards. But blood circulating through the lungs 
at a high pressure, and at the normal rate, gets rid 
of its carbonic acid more rapidly and also more 
perfectly than blood circulating at the same rate 
but at a lower pressure. Hence up to nearly 
middle life every tissue of the body has been con- 
tinuously flushed with a highly oxy- 
genated blood, full of potentiality, and f-^f f " , 

° ^ •' high mtra-pul- 

a well-nourished and healthy organism monary blood 
has thus been filled full of life and f«^^™-«'» 

vigour, and placed at its very best in 

regard to capacity for bodily and mental exertion. 

After the full development of puberty all this 

slowly changes; under the influences already de- 

1 Vide Beneke, Die AUersdisposition, Marburg, 1879, S. 18. 
Also "Ueber das Volumen des Herzens und die "Weite der 
Arteria pulmonalis und Aorta ascendens in den versohiedenen 
Lebensaltern." In Bchriften der Gesellschaft zur Beforderung 
der gesammten Naturwissenschaften zu Marburg, Cassel, 1879, 
S. 5. 


tailed (vide antea, p. 11, etc.) the calibre of the 

aorta becomes gradually greater than that of the 

pulmonary artery. The result of this relative 

diminution in the size of the pulmonary artery is 

that the blood circulates through the 

Effects of a \yxnQS, at a much lower pressure than 

low intrw-pul- ° 

monary blood formerly, the carbonic acid is conse- 

pressurem quently given off more slowly, and 

throughout all the future life there is 

a gradually increasing " venosity " of the blood, as 

the older writers called it, which has an important 

influence on every function of the body. As age 

advances there is also a slowly increas- 

Vo-T^ous civcu- 

latory changes ing tendency of the blood to accumulate 
coincident Jq ^he veins at the expense of that con- 

with this. . , . , . , T T . , 

tamed in the arteries, and the slightest 
disposition to cardiac debility aggravates this ten- 
dency. The result of this is an increasing disposi- 
tion to venous congestion, to remora of the blood in 
the venous radicles, and also to accumulation of the 
serous plasma in the extra-vascular spaces. The 
influence of the increased tension thus produced 
within these spaces upon the intra-vascular blood 
tension, and through that upon the heart, has been 
alreadj'- referred to (vide antea, p. 28). We shall 
presently see that this extra-vascular remora of the 
blood-plasma also forms an element in one very 
important disease, and often gives rise to local 


morbid phenomena of an interesting if not danger- 
ous character. 

Thus, after middle life, the blood is being con- 
tinually shut off from ever-increasing „ 

•' _ ° Effects of these 

areas throughout the body by wither- vascular 

ing of the capillaries; it slowly accu- ctoffesow 

° . . . ^^^ blood. 

mulates in the veins, it is less highly 

oxygenated than formerly, and is thus less fitted 

for promoting the discharge of any of the vital 


But this condition of "venosity" of the blood, 
and of remora of the blood in the veins, — " venous 
congestion," as it is so usually termed, — has been 
recognized by all physicians since the days of Galen 
as "the first condition essential to the formation 
of the gouty diathesis."^ It is the basis of that 

Add to this that in a state of civilization man 
is always supplied with a superfluity 
of foods and drinks, which the habits ,^"X 
of society and the anxiety of his friends Moodresuiting 

, ,!• -pji t i j.n from these vas- 

tempt him, if they do not actually com- '^^j^^ .^^^g,, 

pel him, to partake of four or even are the basis 
„ . , of the gouty 

five times a day. diathesis. 

Moreover, as the bubbling energy of 
youth fails, the mere pleasure of it no longer in- 
cites us to violent exertions, the needs of civiliza- 

1 On Gout. By W. Gairdner, M.D., London: 1849, p. 121. 


tion do not require such exertions from us, and 
the many luxurious appliances of civilized life aid 
and abet the natural indolence that grows upon 
man as age advances, and largely preclude the 
need for any but the most trifling bodily exer- 

Hence this less highly oxygenated blood is 
flooded with a redundancy of nutritive material, 
far in excess of the requirements of the frame, 
which can neither be used up in any of its ordinary 
appropriations, nor fully oxidated in any other 
way, and so excreted. The general metabolism 
is thus impaired, every function of the body im- 
peded, every secretion deteriorated ; all the organs 

Thus we have the Gouty Diathesis fully devel- 
oped ; a diathesis — habit of body — present in 
each one of us after middle life, and which modi- 
fies the organic metabolism of each one of us, both 
in health and in disease. The gouty diathesis is 
only a comprehensive term for all those changes 
in the character and composition of the blood in- 
duced by the evUs of civilization — deficient exer- 
cise and excess of nutriment — multiplied into 
those developmental changes in the vascular sys- 
tem, which are at once the cause and also the con- 
sequent of puberty. 

Gout, on the other hand, is the name given to 


all those modifications of our metabolism caused 
by the gouty diathesis, as well as to g^^toniya 
all the symptoms to which those modi- generic term 
fications give rise. Naturally, after ZZlm- 
middle life gout affects every organ cations of 
of the body, both in its structure and '^^^"^^bTthe 
its function ; in a state of civilization gouty dia- 
we are all, after puberty, more or less 
gouty, and we are gouty in a gradually increasing 

A paroxysm — painful and distressing though it 
be — is a mere episode in the history of gout, and 

an episode indeed to which not a tithe 
. , 1 • 1 1 mi -^ paroxysm 

of the gouty are liable. The sever- of gout is a 
ity of the symptoms are but an acci- ™^" episode 

in its history. 

dent of locality ; and the pain like that 

of angina pectoris itself is but the product of 


It is many a year ago since Cullen rejected the 
term Arthritis as inapplicable to the gouty parox- 
ysm, because it hinted at an inflammation which 
had no existence, and gave it the name of Podagra, 
as expressive of the one fact most undeniable 
about it, that though it may occasionally affect 
other parts, it is most usually a severe pain in the 
foot.i CuUen's description of an attack is still 
as accurate as ever, and the appearance of the 

1 Synopsis Nosologix MethodiccB, Edin., 1815, p. 17, note. 


part affected, is the same now as then, yet we 
seem to have made but little progress in discover- 
ing its true nature. 

If there is one thing more certain than another 
about an acute gouty affection of a joint, it is 
„. ,. ,. that, though often regarded as an in- 

marks of a flammation, it presents none of the 
goutyjomt. characteristics of that process, and 
ends in none of its usual terminations. There is 
never any suppuration, and never any adhesion of 

the opposed surfaces. There is here 
Never any ^'^ 

adhesion or no process of abnormal nutrition, no' 
suppuration, cell-proliferation, no diapedesis of the 
white cells, no true inflammation. 

It may be objected that a gouty joint always 
ends in resolution, and that resolution is one of 

_ , ^. , the natural terminations of inflamma- 

Besolution al- 

loaysincom- tion. But the resolution of a gouty 
^^'^' joint is always incomplete ; even after 

a first attack there is left behind a deposit of urate 
of soda in and around the joint, and this increases 
with each subsequent attack, so that a' gouty joint 
never returns to its pristine condition, but gets 
larger and stiffer with each attack. 

Again, of the well-known Quatuor Notce, the 

Color is often, if not always, wanting ; 

CatorMaraj- ^-^^ temperature of the affected joint 

may even be below the normal. "I 


have found it 97, while that in the mouth at the 
same time was 100." ^ This is quite incomprehen- 
sible except on the supposition that there is some 
obstruction to the free circulation of the pyrexial 
blood through the part affected, and indeed the 
whole history of a paroxysm is most readily expli- 
cable upon this supposition, while at least one kind 
of treatment is quite inexplicable upon any other. 
A paroxysm begins with a sudden attack of 
acute pain, which may pass off as sud- 
denly as it came, leaving the joint ^"^^Zy^l. " 
unaltered; or the pain may increase, 
and become excruciating; the joint swells, becomes 
dusky red, tense and shining, and the veins lead- 
ing from the joint to the dorsum of 

° ■• VarTi turgid 

the foot are dark and turgid. The veins lead off 
attack generally begins with slight •^™™ '^^^'"■* 
shivering; the pain is compared to 
that of a penal boot or thumb-screw ; this torture, 
made unbearable by the slightest vibration, lasts 
till morning — till cock-crow, galU cantu, as 
Sydenham puts it; then slight remission takes 
place, the patient falls into a gentle perspiration, 
and at last gets to sleep. In the morning the 
joint is found swollen, shining, dusky red, and 
the pain is easier. This remission lasts through 

1 Vide Sir Dyce Duckworth's Treatise on Gout, London, 
1889, p. 248. 


the day, but towards evening tlie pain recurs as 
severe as ever, and this cycle of remission and 
exacerbation goes on for four to eight nycthemera. 
Then the crisis is over, the remissions get gradu- 
ally longer and more complete, and 
Paroxysm i • i j- i 

may last from erelong there IS nothing left but a 

a fortnight to numbness which may last for about 
three weeks. „ , . . 

a week. The redness of the joint 
attains its maximum intensity in about thirty 
hours ; it then diminishes or rather gets more vio- 
let in hue as the pain wears away. The oedema 
increases for four or five days, and when it disap- 
pears and the attack is over the joint remains stiff, 
the foot soft and numb, and the gait hesitating for 
other ten or fifteen days. 

Throughout the whole history of a paroxysm 

A paroxysm *^®^® ^® ^° indication whatever of 
of gout not an inflammation ; there is no known in- 

inflammation. n ,- t.- t. n 3 j 

nammation which runs so faxed and 

definite a course, and so invariably terminates in 


On the other hand, if we accept the idea of the 

gouty joint being an infarction, the 

J.Thj OjiCZliOTfh 

suggested as phenomena are easily explicable, and 

anexpiana- ^\^q invariable termination readily ac- 
tio™ of the '' 
condition of counted for. 
the gouty ^j^ infarction is the gorffinsr of a 

joint. & s & 

part with serum, blood, or both; it 


presupposes a block in the circulation, the forma- 
tion of an anBemic area, and the gorging of this 
area with retrograde blood from the neighbouring 
valveless veins.^ 

There is no difficulty in imagining the occur- 
rence of a block in the circulation of any gouty 
person, as we know gouty thrombosis to be in 
them a very common occurrence. Recumbency 
for a few days for some trifling ailment is quite 
sufficient to induce thrombosis in one or more of 
the veins of the extremities in many, necessitat- 
ing three weeks longer in bed than was bargained 
for. In others, some unusual sedentariness of 
occupation is quite sufficient to cause thrombosis, 
which gives rise to no pain unless it be connected 
with some tendinous part such as the heel, where 
indeed it is but slight and evanescent, as it some- 
times is when it occupies but a limited area even 
in the usual point of selection, the junction of the 
metatarsal bone with the proximal phalanx of the 
great toe. 

Granted the block in the circulation, then the 
other phenomena follow in regular sequence as 
a matter of course. Arrest in the onward move- 
ment of the blood in the veins leading from the 
part is speedily followed by their turgescence, 
because the blood flows into them from the sur- 
1 Cohnheim, op. cit.., p. 121. 


rounding capillaries and valveless veins until an 
equilibrium is established between the pressure 
in the occluded area and that within these 
veins .^ 

The sluggish movement of the blood also per- 
mits the accumulation of the red corpuscles within 
the capillaries of the affected area, hence the red 
turgescence of the part, a redness that grows 
duskier the longer it continues. 

Moreover, the remora of the lymph within the 
tissue interspaces not only contributes to the 
tension of the part, but the lymph being highly 
charged with the somewhat insoluble salts of uric 
acid, these may crystallize out during this delay, 
or they may get left behind as a residuum when 
the lymph gets reabsorbed as recovery progresses, 
and thus originate those deposits of urates in and 
around the joint which increase with each subse- 
quent attack. 

The pain is in the later stages largely augmented 
by the increased tension within the part, but pri- 
marily it is due to ischsemia. An acute twinge 
is often the earliest indication of an attack, this 
goes on increasing if the other signs are super- 
added, but the pain passes off at once should the 
circulation rapidly return to its normal, as it not 
infrequently does. 

1 Cohnheim, loc. cit. 


In favour of the idea that a gouty paroxysm is 
due to a local infarction, we have thus, — 

I'int. A gouty joint contains no inflammatory 
exudation, but merely a sero-sanguinolent effusion 
in and around the joint ; and neither in its com- 
mencement, course, nor termination does it cor- 
respond with any known form of inflammation. 

Second. In the gouty diathesis thromboses are 
common enough ; they occur in circumstances and 
under conditions precisely similar to those in 
which we have a paroxysm of gout evolved, but 
a gouty paroxysm never follows unless the throm- 
bosis happens to occupy a position in which it 
necessitates the formation of an infarction. 

Third. When a thrombosis occurs anywhere, 
the time occupied in recovery is precisely the same 
as that usually required for recovery from a fit of 
gout. I well remember an old friend who was 
subject to repeated attacks of gouty aphasia due 
to cerebral thrombosis ; in him the period that 
elapsed before the power of speech returned was 
three weeks, — precisely that usually occupied by 
an ordinary fit of gout. 

Fourth. The acceptance of thrombosis followed 
by infarction as an efiicient cause of the gouty 
paroxysm, not only affords a reasonable and sufii- 
cient explanation of all the concomitant phenomena 
of a fit of gout, but it also supplies a rational and 


intelligible explanation of a mode of treatment 
which has proved highly successful, and which is 
utterly inexplicable in any other way. 

When Boerhaave in Section S of his 1275th 

aphorism talks of the cure of gout being carried 

out, " Exereitio magno, continuato equi- 

cuegou tationihus in cere puro, turn frictionibus, 

cessfuiiy motibusque partium scepe iteratis" ^ it is 

mZltellone. ^^^^ probable from the context that 

he refers to the cure of an acute attack, 

and not merely to massage and other forms of 

friction as employed to remove the rigidity of gouty 


At all events we know that Sir William Temple 
— who was ambassador at the Hague when Boer- 
haave was born — was aware of this method of 
cure, for he says that in one part of the East 
Indies, "the general remedy of all, that were 
subject to the gout, was rubbing with hands ; and 
whoever had slaves enough to do that constantly 
every day, and relieve one another by turns, till 
the motion raised a violent heat about the joints 
where it was chiefly used, was never troubled 
much, or laid up by that disease." ^ Temple also 

1 Aphorismi de cognoscendis et curandis morbis, ab Her- 
manno Boerhaave, ed. 3tia, Lugdun, Batavorum, 1727, p. 312. 

2 Boerhaave was born in 1669 ; Temple retired from the 
embassy in 1671. Vide An Essay on the cure of gout by Moxa, 
in The Works of Sir William Temple, Bart. Edinburgh, 1754. 
Vol. ii., p. 127. 


says that the Rhyngrave, whom he knew very well, 
never used any other remedy for the gout, to 
which he had long been subject, except on the first 
indication " to go out immediately and walk, what- 
ever the weather was, and as long as he was able 
to stand, and pressing still most upon the foot that 
threatened him ; when he came home he went to 
a warm bed, and was rubbed very well, and chiefly 
upon the place where the pain began. If it con- 
tinued or returned next day, he repeated the same 
course, and was never laid up with it ; before his 
death he recommended this course to his son, if 
ever he should fall into that accident." ^ Temple 
also tells of one of his brother's gamekeepers who 
when seized by a fit of gout never laid himself up, 
but walked after his deer or his stud from morning 
to night, in spite of the pain, till he got ease.^ 
This reminds us of the statement by Mr. Apperley 
— the well-known Nimrod of old days — that a 
friend of his when threatened with a fit of gout, 
after a good dinner and his quantum suff. of wine, 
warded it off by walking the soles of his pumps 
quite through before going home to bed. Dr. 
. Gairdner also relates the case of a friend of his 
own, an old gentleman of eighty-five, whose con- 
stant remark to his physician and his family when 
he was seized with a fit of gout, was, " I'll walk 
1 Loc. cit. ^ Loc. cit. 


it off " ; and walk it off he did. This same old 
gentleman often quaintly remarked to his friends, 
" Go to bed with the gout, and it will surely go 
to bed with you, and be mighty bad company " ^ 
— a statement which curiously resembles that by 
Temple that sufferers from gout carry it presently 
to bed, and keep it safe and warm, and indeed lay 
up the gout for two or three months, while they 
give out, " that the gout lays up them." ^ 

In the beginning of this century a namesake of 
my own, apparently quite unaware that anything 
had ever been written in regard to the treatment 
of acute gout by friction, wrote a paper on what 
he called a " New, simple, and expeditious method 
of curing gout,"^ advocating massage for this 
purpose. He narrates three cases in which this 
treatment was perfectly successful. One of these 
patients at first rejected the treatment as entirely 
inapplicable to him, as he had attempted to touch 
his own toe, and he might as well have applied 
"living fire." Nevertheless, firm pressure and 

1 Gairdner, Ore G^out, London, 1849, p. 114. 

2 Op. cit., p. 128. 

8 By W. Balfour, M.D. Vide Edinburgh Medical and Surgi- 
cal Journal, Vol. xii., p. 432. And none of us have forgotten 
the old gentleman in Sandford and Merton who was cured of his 
gout by toeing starved and locked up In a room without a seat, 
the floor of iron heing gradually heated till continual move- 
ment became a necessity. 


friction entirely removed the pain in ten minutes, 
and in two days he was going about as usual. 

Facts such as these are worthy of the most care- 
ful consideration, and are only explicable on the 
theory that the essential lesion in an attack of acute 
gout is the formation of a thrombosis — at first 
probably a mere stasis — in such a situation that 
an infarction is a necessary consequence. 

In the gouty — that is, in all of us after middle 
life, more or less — thrombosis is always a possible 
occurrence, and it plays a manifold r81e, the impor- 
tance in each case depending on the position of the 

Thus thrombosis of the cortical vessels plays a 
notable part in progressive softening of the brain ; 
the symptoms varying according to the ^ , ^^ 

•I ^ ■! o o Gouty throm- 

part affected. Thrombosis or stasis basis plays a 
in the motor areas is often limited in "^^^^Md role. 
extent and temporary in character, so that the 
resulting paralysis may be slight and evanescent, 
or more extensive, more complete, and permanent. 
The same may be said of Aphasia, — so common 
in the gouty, — which may be either amnesic or 
motor in character ; and either incomplete and 
temporary; complete and yet tempo- 


rary ; or both complete and permanent ; symptoms 
the last rare in purely gouty cases, from cerebral 
Incomplete attacks of a paralytic char- 


acter may be but slight and pass off rapidly, like 
the twinges about the heel and toes which quickly 
vanish. Or these attacks may be more complete 
and yet quite temporary in their nature, lasting 
just about the usual time of a gouty paroxysm — 
from two to three weeks. Single attacks of corti- 
cal thrombosis are seldom of much consequence, 
but by frequent recurrence they may ultimately 
produce most serious results. On the other hand, 
central thromboses are always most serious ; some- 
times one or both pupils may be dilated; the 
breathing may be deep and regular, like the blow- 
ing of a bellows ; and death may occur in a few 
hours, preceded by a considerable rise of tempera- 
ture, coma, or muttering delirium, and sometimes 
by convulsions. 

Venous thromboses of the limbs are more trouble- 
some than dangerous, in those who are otherwise 
healthy. But as there are many to 

Thromboses of ■, n ■ j. j t_ 

limbs whom a day or two oi recumbency 

always means the blocking of one or 
more of the veins of the extremities, even a trifling 
catarrh to them means three weeks more of bed 
than it does to ordinary people. It is only when 
such a patient is out of health that micro-cocci 
invade these clots, which then break down and 
give rise to showers of poisonous emboli, producing 
blood-poisoning of a serious character with scattered 


septic abscesses. Nay, it sometimes happens, 
especially in connection with a dilated senile 
heart, that perfectly aseptic thrombi in some of 
the smaller veins soften and break down into 
showers of minute emboli, with no other result 
but a sudden rise of temperature, putting on the 
appearance of an ague of irregular type, and pro- 
longing convalescence till blood and heart have 
both improved in character. Arterial thromboses, 
which are often the result of embolism, though 
sometimes purely autochthonous, are much more 
serious, and are apt to lead to senile gangrene 
of the part to which the artery affected is dis- 

Thrombosis of the gastric veins after middle 
life is followed by similar results to jiggy^n^^f 
those that happen at an earlier age ; gastric 
there is pain after food, ulceration, ™'" "*"' 
and often severe hsematemesis. Should the ulcer 
be at or near the pylorus, there may be no vomit- 
ing, only dark-coloured stools — melsena. 

It is not alone, or chiefly, the altered cdnstitu- 
tion of the blood that gives rise to ^auseofthe 
the formation of thrombi. It is not formation of 
even stagnation of the circulation that ' '''"" *' 
causes the blood to coagulate in the veins. These 
may assist, but so long as the endothelium is 
intact and performs its functions normally, the 


blood remains fluid.^ The conclusion from this 
is, that the sluggish venous circulation has so 
impaired the vitality of the endothelium that 
thrombosis is at once precipitated, more especially 
in certain positions, by whatever further impairs 
the constitution of the blood or makes its move- 
ment more sluggish. 

In advanced arterial atherosis, so common in 
gouty patients, the endothelium occa- 

Sourceof sionallv dies, gets washed off, and so 
gouty emboli. . . 

permits calcareous spiculae to project 

naked into the vascular lumen ; upon which the 
blood coagulates. In arteries of a moderate 
size these coagula often become autochthonous 
thrombi and completely block the artery. In 
larger vessels the coagula projecting into the 
blood current occasionally get broken off and 
carried as emboli into smaller arteries, which they 
either block completely, or they may block it in- 
completely, and thus form a nucleus for a throm- 
bus, which ultimately completes the occlusion. 
In this way embolism of the brain occasionally 
gives rise to ingravescent symptoms, simulating 
those caused by recurrent hemorrhages. 

^Vide Colinheim, op. cit., Vol. i., pp. 174 and 177; also 
Baiimgarten, Die Sogennante Organisation des Thrombus, 
Leipzig, 1877 ; also Senftleben, Virchow's Archiv, Ixxvii., S. 
421 ; and Birk, Das Mbrinferment im lebenden Organismus, 
Dorpat, 1880. 



Irregularity of nutrition being an indication of 
the arouty diathesis, it has come to „.. , 

^ ■' ' Ridyed and 

pass that longitudinally ridged (stri- furroioed 
ated) nails have been regarded as a '*"' ^' 
sign of gout (Fig- 8), and so they doubtless are. 
These ridges are not often seen before middle 
life ; they sometimes implicate the whole surface 
of the nail ; at other times there is 
but one strongly marked ridge from 
matrix to tip, and even this may be 
irregularly interrupted by narrow, 
transverse furrows. These ridges are 
a sign of the gouty diathesis, but 
have no connection whatever with a 
gouty paroxysm ; when the nails are 
thin they often split, and are sometimes very 
troublesome, but this chiefly in advanced life. 
Except when thej^ split such nails are 
more curious than important. It is 
otherwise with the transverse furrows 
occasionally found running across the 
nails (Fig. 9). These are best marked 
on the thumb-nail, which is the thick- 
est, and are always an indication 
of a serious illness overlived. Beau 
in France, and Wilkins here, get the credit of 
having first directed professional attention to 
these furrows ; but, indeed, their presence and 

Fig. 9. 


signification have been known from time imme- 
morial, and there is not a farrier or horse-cowper 
who does not understand the importance of a 
transverse furrow on the hoof of a horse, or who 
is not quite up to the advantage of new shoes and 
fresh rasping of the hoof where such a tell-tale 
exists. As the thumb-nail takes six months to 
grow from matrix to tip, the position on the nail 
indicates with tolerable exactness the period 
elapsed since the illness; it is but seldom that 
an attack of gout is serious enough to produce such 
a furrow. 

SeberderCs hnohs are very distinctly connected 

with the gouty diathesis, though they 

Heberden's ^^^ jjq^ always Connected with any 

knobs. . 

paroxysm. Heberden himself says: 
" What are those little hard knobs, about the size 
of a small pea, which are frequently seen upon 
the fingers, particularly a little below the top 
near the joint? They have no connection with 
gout, being found in persons who never had it ; 
they continue through life ; and being hardly ever 
attended with pain, or disposed to become sores, 
are rather unsightly than inconvenient, though 
they must be some little hindrance to the free 
use of the fingers."^ These knobs are common 

1 Commentaries on the History and Cure of Diseases, by 
William Heberden, London, 1803, 2d ed., p. 148. 



enough, and there are few physicians of any 
experience who have not had an opportunity of 
watching their development. They sometimes 

Fig. 10. — At a two of Heberden's knobs are seen at the base of 
the distal phalanx of the forefinger; over the head of its 
metacarpal bone, 6, there is a tophaceous mass. 

rapidly grow after an acute affection of the 
fincrers, with many of the characteristics of a 
true gouty paroxysm ; at other times they are of 
slow and gradual growth, accompanied by the 
ordinary phenomena of gouty dyspepsia, but at- 


tended by no more remarkable local phenomena 
than occasional twinges of pain about the joints, 
and an occasional sense of fulness and stiffness of 
the fingers, much aggravated, if not entirely in- 
duced, by gastric disturbance. For diagnosis, 
however, and certainly for treatment, we have to 
distinguish between Heberden s knohB and Hay- 
garth's nodosities?- The knohs are extravascular 
deposits in the neighbourhood of the smaller 
joints, chiefly of the fingers, but they may be 
found about the toes also, and appear as gouty 
pearls on the cartilage of the ear. They begin 
like small peas, or at least are scarcely noticed 
till they are about this size, but they sometimes 
attain a considerable size, and produce great and 
irregular deformity of the hands or other parts 
affected ; they are composed of urate of soda, and 
are popularly known as chalkstones. 

The nodosities, on the other hand, are associated 
with rheumatoid arthritis, and not 

Haygarth's ^j^j^ ^ ^^ ^^^ j.^^^ „ exostotic 

nodosities. o ./ ./ 

growths, from the margins of the 
articular surfaces, as well as from the periosteum 
and bone in the neighbourhood of the diseased 
joints." 2 These nodosities lead ultimately to 

1 A Clinical History of Diseases, part 2, of Nodosity of the 
Joints, by John Haygarth, Bath, 1805. 

^ A Treatise on Bheumatic Gout, by Robert Adams, M.D., 
London, 1873, p. 16. 



anchylosis of the joints ; and the deformity of the 
parts affected, when the hand is at fault, is "in- 
variably associated with a characteristic adduction 
or inclination of all the fingers towards the ulnar 
side of the hand."i 
The knobs are due to 
impurity of the blood, 
the nodosities to dis- 
ease of the bone. 
Gout is peculiar to 
man ; rheumatoid ar- 
thritis he shares with 
the lower animals, 
notably with the 
horse. For nearly 100 
years the impurity in 
gouty blood has been 
known to be uric 
acid, usually present 

as urate of soda.^ This uric acid is due to defective 
oxidation of the effete material in the blood ; 

1 Adams, op. cit., p. 252. 

2 In 1797 Tennant and "WoUaston established the fact that 
tophi are composed of urate of soda ; but Charcot rightly says, 
"the period of positive knowledge dates from Garrod's re- 
searches in 1848." Clinical Lectures on Senile and Chronic 
Diseases, by J. M. Charcot, New Sydenham Society's Trans- 
lation, 1881, p. 127. Vide also A Treatise on Gout and Bheu- 
matic (rout, by Alfred Baring Garrod, M.D., London, 1870, .3d 
edition, p. 49, etc. 

Fig. 11. — Haygarth's nodosities. 


instead of urea being formed and excreted, 
the lower compound, uric acid, is formed and 
retained. At certain parts of the body — about 
the joints, cartilages, and tendons — the circu- 
lation, never very active, gets delayed as age 
advances. The blood-plasma, flooding the tissue 
interspaces, is reabsorbed but slowly; the urate 
of soda, never very soluble, crystallizes out on 
some slight provocation, and gradually grows to 
gouty pearls on the ear, to Heberden's knobs on 
the fingers, and to so-called tophaceous deposits 
elsewhere. The synovial oil lubricating the joints 
and tendons is less perfectly elaborated than 
formerly; hence the gouty stiffness and pain on 
movement, aggravated by a certain amount of 
tension in the tissue interspaces, vrhich is always 
present, and is worse at times. Moreover, the 
uric acid, or urate of soda, not only forms knobs 
and pearls in the situations specified, but now and 
then crystallizes within the sheaths of the tendons, 
notably that of the tendo AchilUs, giving rise to 
a grating sensation on movement, which is often 
painful. The same thing may, indeed, be found 
in any of the extravascular spaces ; for senile 
remora and the gouty diathesis modify the circu- 
lation throughout the whole body, as well as 
every vital process, whether it be normal or ab- 


There is one other symptom of gout which 
deserves special mention, and that is a "peculiar 
aura or rapid twittering motion under the skin, 
as it were, chiefly in the back and limbs." ^ This 
twittering of the superficial muscles „ . . .,, 

o -"^ Gouty twitter- 

is limited to a small area; it comes on ingofsuper- 
suddenly and is of short duration; in Malmusde,. 
character it resembles very much an attack of 
tremor cordis, but being quite superficial, it is 
naturally much less alarming. Repeated attacks 
of this twittering sometimes precede an attack of 
gout, but this symptom is often found where only 
the diathesis prevails. Its causation is quite as 
inexplicable as that of the tremor cordis itself. 

The infarction theory of what is called a fit of 
gout, while it accords with and explains all the 
obvious facts connected with an attack, still leaves 
many of the more recondite phenomena unex- 
plained. For example: the marked hereditary 
character of true gout, and the remarkable fact 
that while all of us acquire the gouty suferersfrom 
diathesis as age advances, not a tithe Heberden's 
of us ever suffer from a paroxysm. ^^"^"^^^^^ 
Yet these are not more inexplicable oxysmal 
than the fact that those who suffer " "^ 
from Heberden's knobs rarely have any so-called fit 

1 Vide Contributions to Practical Medicine, by James Begbie, 
M.D., Edinburgh, 1862, p. 6. 


of gout — SO rarely that Heberden himself says 
of these knobs, "they have no connection with 
gout." Yet these digitorum nodi are certainly 
inseparably connected with the gouty diathesis, of 
which they are signs as easily recognized and as 
distinctive as enlarged cervical glands and irregu- 
lar cicatrices are of struma. 

The heredity may be partly of structure; that 
as yet we do not know. It certainly is of function, 
„ , , and the function is that of the stomach. 

Gouty dys- 
pepsia is often We know this to be inherited, because 

m ente . iQ^xg before there can be any question 

of acquirement we find the gouty dyspepsia in full 

swing ; nay, more, in quite young children we not 

only find the gouty intolerance of certain articles 

of food, but we also find that when these articles 

are consumed their ingestion is followed not only 

by all the usual dyspeptic symptoms, but also by 

Gouty dys- Stiffness and swelling of the digits. 

pepsiamay Gouty dyspepsia means a feeble and 

be curable. ■ j? j, t j.- • • ^ 

imperfect digestion ; occurring in early 

life, it must be largely a matter of inheritance, 
though it may be aggravated by injudicious feed- 
ing in infancy, and possibly enough it may even 
be to some extent acquired in this way. I need not 
say that as care and diet can do much to relieve 
gouty dyspepsia at any age, so, at an early age, when 
as yet unaccompanied by any structural alterations, 


it may not only be greatly relieved, but may even 
be cured. 

Gouty dyspepsia in advanced life can always 
be greatly relieved ; but as the cause is structural 
and permanent, watchful care is always a lifelong 
necessity. The essential element of gouty dys- 
pepsia is feebleness of digestion. The gastric juice, 
like all the other secretions, is secreted at a low 
pressure, it is poor in quality, and defective in 
quantity ; hence imperfect digestion. Some of the 
food escapes the action of the gastric juice, and 
instead of being formed into healthy chyme it 
breaks up, under the influence of heat and moist- 
ure, into various compounds productive of dis- 
comfort in the stomach and of sundry ill effects 
when absorbed into the blood. The food may 
undergo acid fermentation, acetic and butyric 
acids being set free, which irritate the gastric 
mucous membrane, inducing a catarrhal condi- 
tion with excess of mucus, which hampers the 
primary digestion in the stomach, and by extend- 
ing along the duodenum and bile ducts may in- 
terfere with the free passage of the bile and 
thus impede secondary digestion. A sense of 
fulness and oppression, with pain and acidity or 
more often flatulence after meals, indicate that 
digestion is being interfered with, and result in 
the fluttering and irregular heart, so usual a con- 


comitant of gouty dyspepsia. The irritated and 
congested condition of the gastric mucous mem- 
brane is the great cause of the gouty Bulimia, 
which is not only the result, but also a very effi- 
cient cause, of much of this dyspepsia. Then we 
have the disturbed sleep — the gouty insomnia, 
the irregular bowels, and the lateritious sediment 
in the urine, which together make up those ex- 
ternal indications that reveal to the most unob- 
servant the existence of the gouty diathesis. 



There are several important organs in the 
body which are very gravely affected by the 
changes in the circulation due to advancing age, 
notably the liver and the kidneys. In their turn, 
the alterations in the structure and functions of 
these organs, thereby induced, very materially 
modify all the organic processes during the future 
progress of life. 

Oliver Wendell Holmes says that the most satis- 
factory and comforting opinion that can be given 
to a patient, is to tell him that he suffers from con- 
gestion of the portal system. And there may be 
truth in this view ; but to tell him that he suffers 
from too much or too little bile, or 

Bile but the 

from biliousness generally, expressions drainage of a 
never out of the mouth of a valetudi- '«'■£'« ™«»"- 

. factory. 

narian, is to make use of words without 

meaning, now that we know that bile is only the 



drainage of a large manufactory, and is itself 
apparently of but little use in the animal economy .^ 
Indeed, the discomfort which we know to accom- 
pany the absence of bile from the stools must now- 
adays be looked upon as entirely due to the cessa- 
tion of the manufacture, and not to the absence of 
the product from the intestinal contents. The 
amount of bile secreted in a day amounts to some- 
what over a pint (638 ccm.),^ and though this is 
nearly all reabsorbed, and the movement of the bile 
and pancreatic secretion may thus be regarded as 
the analogue of the abdominal circulation of the 
Gasteropods, yet as these secretions are most 

1 " From June, 1890, to the present date, March, 1892, every 
drop of bile has been poured out on the surface, and there has 
been no evidence that any has entered the duodenum. Never- 
theless, her health and strength have steadily improved. . . . She 
is fat, and must weigh eleven or twelve stones. She tells me 
that since her return home she has never had a day's illness, that 
she is up every morning at her household duties at five o'clock. 
She states that her appetite is very good, and that she can eat 
all kinds of food, even the most fatty, with perfect impunity. 
Her bowels move once a day without medicine. It would be 
impossible to adduce stronger evidence against the view that 
bile plays any important part in the digestive process." Vide 
"Further Observations on the Composition and Flow of the Bile 
in Man." By D. Noel Paton, M.D., Laboratory Reports of the 
Boyal College of Physicians, Edinburgh, 1892, Vol. iv., p. 44. 

^ Vide " On the Composition, Flow, and Physiological Action 
of the Bile in Man." By D. Noel Paton, M.D., F.R.C.P. Ed., 
and John M. Balfour, M.B., CM., Laboratory Reports of the 
Royal College of Physicians, Edinburgh, 1891, Vol. iii., p. 193. 


copious just after the ingestion of a meal, they 
must to some extent relieve the vascular turgor 
always greatest at that time. An active liver is a 
great relief in cases of weak, dilated „ 

o ' Free secretion 

hearts, and the abdominal circulation of uie relieves 

just referred to afCords a reasonable « "^"^ '"=«'•*■ 
explanation of this. In weakly subjects, to obtain 
this relief it is enough to employ an appropriate 
cholagogue in a dose sufficient to act upon the 
liver alone, without purging. 

The two great manufactures of the liver are 
urea and glucose. Urea is the chief ultimate 
product of the oxidation of nitrogenous bodies, 
and when these are in excess, or when there is 
a hypo-oxygenated venosity of the blood, as hap- 
pens in all more or less after middle life, but 
especially when the heart gets dilated, then we 
have the less oxidized product — uric acid — 
formed, and its neutral salts saturating the system 
— the gouty diathesis in full swing. Under these 
conditions there is always congestion, often enlarge- 
ment of the liver. There is never any difficulty in 
detecting in the urine the deficiency of urea and 
the excess of uric acid and its salts ; but there is 
more, for in all cases of congested and gouty liver 
we get in the urine, with Moore's test (liquor 
potassse), a yellow colour which deepens with the 
congestion, until in many cases we have gouty 


glycosuria fully developed. There seems to be a 
regular gradation from the faintest tinge of colour 
to unmistakable sugar, detectable by every known 
test, so that it seems a little difficult and somewhat 
invidious, to say up to this point there has been no 
sugar, now there is. Mucin (Nucleoalhumin) in 
the urine strikes a yellow colour when the fluid is 
boiled with liquor potassse,^ while uric ^ and gly- 
curonic ^ acids, kreatin and kreatinin,* all decom- 
pose the copper in Trommer's and in Fehling's 
tests when boiled with them; and as these are all 
present in gouty urines, a yellow colour is con- 
tinually to be found in such urines when these 
tests are employed. The fermentation test itself 
may be fallacious, because other matters besides 
sugar are decomposed under the influence of 
ferment.^ So long as the sugar is in a minute 
quantity, it seems scarcely possible to say whether 
it is actually present or not ; when it is found in a 
larger amount, the difficulty lies in determining 
whether we have to do with a true diabetes or 

' V. Jaksch, Klinische Diagnostik, 3e Auflage, Wien u. 
Leipzig, 1892, S. 327. 

2 V. Jaksch, op. cit., S. 328. 

s Ashdown, Proceedings of the Boyal Society of Edinburgh, 
Vol. xvii., p. 58. 

* V. Jaksch, loe. cit. 

' Thudichuui, Pathology of the Urine, London, 1877, p. 429 ; 
V. Jaksch, op. cit., S. 329. 


merely with a gouty glycosuria. To determine 
this, we have to fall back upon other subsidiary 

Gouty glycosuria has a knack of turning up at 
odd times and in an unexpected man- Qasescf 
ner. More than a dozen years ago an gouty 
elderly gentleman presented himself sv^osmxa. 
to me with a dilated heart, an enlarged liver, very 
considerable general dropsy, marked cedema of the 
lungs, and about one-third of albumin in his urine, 
which was scanty. He was puffy all over from 
general cedema, but seemed also to be well 
nourished, and had no particular thirst, nor any 
ravenous appetite ; just about the kind of case in 
which one would least think of looking for sugar 
in the urine, yet, on examination, over five per 
cent of glucose was detected. The coexistence 
of albumin with glucose in the urine is not 
usually regarded as favourable to the patient, but 
the prognosis depends, not upon the coexistence 
of these substances, but upon the probable cause 
of the presence of them both. In this case the 
dilated heart was the evident cause ; venous con- 
gestion of the kidneys leading to albuminuria, 
and venous congestion of the liver to glycosuria. 
A dilated heart is an improvable, if not always a 
curable, organ, even though the dilatation is senile 
in character, and the old gentleman made a most 


excellent recovery. His heart improved in a re- 
markable manner, the dropsy passed entirely 
away, and the glycosuria disappeared. He lived 
for several years, and was able to carry on his 
business comfortably. He had to do a good deal 
of travelling and occasionally caught cold, and 
this invariably broke down his cardiac compen- 
sation and brought about a return of all his 
symptoms, but never to so considerable extent 
as at first. I saw him occasionally at long 
intervals for these relapses, but the illness was 
always taken in time, and there was never more 
than a trace of either sugar or albumin to be 
found. At fijst he was dieted, but not strictly, 
and more for the sake of his heart than of his 
glycosuria ; there was never any subsequent need 
for this. He died some years ago from pneu- 

Another old gentleman, sixty-eight years of age, 
on his way to Vichy, whither he had been sent by 
two physicians on account of gouty symptoms, 
was picked up by a London specialist, who de- 
tected a considerable quantity of sugar in his 
urine. This gentleman was told that his disease 
had been misunderstood, that he had diabetes and 
not gout, that he need not go to Vichy, but should 
return home and follow the regimen prescribed, 
which, if it did not cure him, would certainly 


alleviate his symptoms. Unfortunately, the 
patient's former advisers had not previously 
tested his urine for sugar, and the scene on the 
patient's return must be left to the imagination. 
By and by this patient fell into my hands. I 
ascertained that he was well nourished, and had 
not been losing flesh; that he had hard, tortuous 
arteries, and a failing heart; a sluggish liver, not 
markedly enlarged ; and that his urine was loaded 
with uric acid, which crystallized out as a copious 
sediment ; that the specific gravity of the urine 
was 1028, and that it contained about five per 
cent of sugar. I had no difficulty in telling the 
patient that his former attendants had undoubt- 
edly erred in not ascertaining the presence or 
absence of sugar, but that otherwise their opinion 
was entirely correct, and the presence of glyco- 
suria only confirmed their view, and was of no 
material importance in the case. Naturally this 
patient had to be dieted for gout, but not for 
diabetes, which did not exist. In no long time 
the arterial degeneration began to affect the 
brain ; the mind, hitherto strong and dogmatic, 
began to waver and have fancies which the patient 
could not distinguish from realities, though aware 
there was a difference which he could neither de- 
scribe nor account for. By and by there was 
a marked declension of bodily vigour, but the 


patient kept well nourished to the last. He died 
of cerebral hemorrhage several years subsequent 
to the episode referred to, the glycosuria having, 
to my knowledge, persisted up to a few weeks 
before his death. 

Again, about fourteen years ago a publican 
chanced to be in a railway accident. Some months 
subsequently he was found to be passing sugar, 
and his ailment was dubbed traumatic diabetes 
by his medical advisers. He was also supposed 
to be suffering from several obscure nervous ail- 
ments due to spinal concussion. In the course of 
his action against the railway company, his dia- 
betes was represented as of a most serious charac- 
ter, traumatic in origin and due to the accident; 
six years were assigned as the utmost limit of 
his life. I found this patient to have a dilated 
heart and a large liver ; also that, like many other 
publicans, he was a free liver. He was fat and 
well nourished; and in spite of having passed a 
considerable quantity of sugar daily for many 
months, and probably for years, there was not 
only no emaciation, but also neither thirst nor 
ravenous appetite. For these and other reasons 
I had no difficulty in declaring that this patient 
did not suffer from diabetes, either idiopathic or 
traumatic ; that he had only gouty glycosuria, 
which in itself would not shorten his days, and 


which had probably existed for several years 
before the date of the accident. This patient 
still survives to attest the correctness of my 
opinion, in excellent health, passing as much 
sugar as ever, and in the full enjoyment of 
the exceptionally heavy damages which the jury 
awarded him. 

These three cases may serve to give an idea of 
the various circumstances in which gouty glyco- 
suria may turn up, and in which it is of conse- 
quence to remember that glycosuria is not diabetes, 
that the mere presence of sugar in the urine is 
not a disease, that it is not of uncommon occur- 
rence in gouty people, and that it is specially apt 
to be found when the heart is dilated and the 
liver enlarged. In these cases of glycosuria, even 
when the quantity of sugar passed is considerable 
(as much as five per cent), there is no emaciation, 
and there is a possibility of a cure. Strict dieting 
is quite unnecessary in such cases, as even though 
the sugar may never disappear from the urine, its 
persistence is not accompanied by wasting of the 
body or by any other serious symptom. The sugar 
seems to be excreted simply because it is in excess 
of the requirements of the system, either as a 
result of the superfluity of nutriment ingested, or 
of a diminished consumption from deficient mus- 
cular exertion; probably both of these circum- 


stances have each a share in bringing about the 
ultiroate result. Gouty glycosuria as a rule is 
easily controlled by regulation of the diet, and 
many reputed cures of diabetes have probably been 
cases of this character. 

The connection between the kidneys and the 
I, .,.,., . heart has for long been a subiect of 

Possimhty of o J 

a reciprocal great interest to the profession. We 
'tween the know that heart failure gives rise to 

kidneys and albuminuria through the intermediacy 

the heart. <. ,• £ j.t t • j \, j. 

of congestion oi the kidneys, but 

whether disease of the kidnej-'S is of equal im- 
portance in influencing the condition of the heart 
has long been a subject of controversy, and the 
literature bearing upon this problem is both volu- 
minous and important. 

There is no form of kidney affection, any more 
than there is any other kind of disease, which 
is not occasionally associated with disease of the 
heart in some one or other of its forms, and that 
either accidentally or for sundry efficient reasons. 
But there is one form of heart affection so invaria- 
bly associated with one particular form of kidney 
disease that, for sixty years past, the relationship 
has been assumed to be one of cause and effect, 
while professional opinion has not yet decided 
which of the two ought to be regarded as the 
cause and which as the effect. 


The almost invariable coincidence of the red 

contracting kidney with hypertrophy of the left 

ventricle of the heart did not escape 
, . !■ -r. • 1 ^^ cirrhotic 

the accurate observation of Bright, udney ahoays 

He sought an explanation of this in associated 
the supposition that " the altered qual- trophy of the 

ity of the blood so affects the minute '■^A ventricle 
. , . of the heart. 

and capillary circulation as to render 

greater action [of the left ventricle] necessary 

to force the blood through the dis- ^^.^ ^^, 

tant subdivisions of the vascular sys- explanation 

tem."i "-^ *''"'• 

But Bright overlooked the fact that in other 

renal diseases M^here the blood is also notoriously 

impure, from the admixture of urinary 

constituents, no such hypertrophv of **"**"•'■ 

' J r r J ficiency. 

the left ventricle occurs. Bright also 

failed to shovr that the blood is always impure 

before the cardiac hypertrophy commences. 

Traube, on the other hand, pointed out that 
hypertrophy of the left ventricle is 
not the result of blood impurity, be- ^™"*''' 
cause it does not accompany every 
form of diffuse renal disease, but is only found 
in connection with the cirrhotic kidney. And he 
propounded the doctrine that this hypertrophy is 
the result of the call for increased exertion made 
1 Guy's Hospital Beports, Vol. i., p. 396. 


upon the heart by the rise of the intra-arterial 
blood pressure, a rise which he believed to be due 
to the obliteration of so many arterial branches 
within the kidneys with the Malpighian tufts 
attached to them.^ But Traube overlooked the 
fact that cardiac hypertrophy is not found asso- 
ciated with every form of contracting kidney, 
notwithstanding a similar limitation of the intra- 
renal capillary area, but is only found in connec- 
tion with the red, granular, cirrhotic kidney. 
We know, also, that destruction of one or both 
kidneys, congenital or acquired (cys- 

. *" . , tic kidneys, hydronephrosis, extensive 

insufficient. j ^ j x- ' 

embolic cicatrices, etc.), extirpation of 
one kidney, amputation of one or more limbs, are 
all of them accompanied by a much greater limi- 
tation of the capillary area than ever happens in 
any case of cirrhotic kidney, and they are never- 
theless entirely without influence in inducing 
any intra-arterial rise of blood pressure. Traube 
also neglected to make sure that the heart was not 
already affected before the commencement of the 
kidney disease. 

According to Sir George Johnson : " The pri- 
mary and essential structural changes consist in a 
desquamation, disintegration, and removal of the 
renal gland-cells, . . . changes in the glandular 
J Q-esamrnelte Beitrdge, Band ii., S. 290, etc. 


epithelium, the result of a modified cell-nutrition, 
consequent on a morbid condition of 
blood associated with gout," various ^jIj^^'I 
forms of dyspepsia, etc.^ Johnson be- pathology of 
lieves that the kidneys, being no longer f^^^^''"^'" 
able fully to discharge their function, 
owing to destruction of their tissue, the renal 
arterioles take on a stop-cock action to cut off 
that excess of blood which is no longer required, 
because it can no longer be depurated. This per- 
sistent action of the arterioles he naturally believes 
to result in hypertrophy of their muscular coat. 
In consequence of the failure of the kidneys to 
discharge their function the blood is necessarily 
impure, and more or less unfit for the perfect 
metabolism of the tissue. To cut off this unsuit- 
able nutriment from the tissues, Johnson sup- 
poses that the systemic arterioles also take on 
a stop-cock action, while for the very necessary 
purpose of maintaining the circulation at its norm, 
in spite of this increased peripheral obstruction 
and consequent rise of blood pressure, the left ven- 
tricle is forced to make extra exertion, and con- 
sequently hypertrophies.^ But Johnson's theory 
postulates too many problems as yet unsolved 

1 Johnson, Medical Lectures and Essays, London, 1887, p. 
700, etc. 

'^ Johnson, op. cit. , p. 705. 


and unaccepted by modern physiology to be of 
Is unsatisfac- any pathological value. This theory 

tory because -^ ^^^^ -^^ incompatible with any 

based upon ^ ^ •' 

views unac- relative cardiac hypertrophy preceding 

ceptedby ^-^^ kidney disease. Johnson conse- 

modern •' 

physiology. qtiently ignores this. 

Next to Traube's, the theoretic pathology of the 
cirrhotic kidney which has most impressed the pro- 
fession, has been that of Gull and 
Gull and Sutton. They deny any direct causal 

Sutton s pa- •' j j 

thoiogy of the connection between renal cirrhosis and 

tZnlT liypertrophy of the left ventricle of the 

heart. They hold that these two con- 
ditions are the result of one general affection of 
the arterial system, to which they have given the 
name of arterio-capillary fibrosis, or hyalin-fibroid 
disease of the arteries.^ Gull and Sutton acknowl- 
edge two forms of contracting kidney. One of 
these occurs as a local disease, and in most cases, 
if not in all, is the product of an acute nephritis. 
This form may occur at any age, and is unattended 
by any change in the heart, and by very little, if 
any, recognizable change in any of the other organs 
in the body. The other form of contracting kidney 
is not common before forty years of age, is often 
associated with hypertrophy of the heart, diseased 
vessels, and more or less widespread changes in 
' Medico- Chirurgical Transactions, 1872, Vol. Iv., p. 273, etc. 


other organs.^ In these cases the kidney affection 
is not always the primary disease, nor can the other 
organic failures be attributed to the kidney disease. 
According to Gull and Sutton, the arterio-capillary 
fibrosis primarily affects the vascular system — to 
wit, the arterioles ; and it invades the other organs 
— the heart, the kidneys, the lungs, the brain, the 
spinal cord, etc., not simultaneously, nor in any 
sequential manner, but as it were casually, as part 
of a widespread cachexia which has its basis in the 
vascular system. 

But a widespread arterial degeneration, rarely 
found before the age of forty, has a suspiciously 
close resemblance to senile degener- 
ation, and the results described as fol- ^'*'*p"- 

tholoc/y closely 

lowing hyalin-fibroid alteration of the resembles, in 

arterial coats are precisely similar to »'s'«»fo''2/«"'^ 
■■^ •' results, senile 

those originating in failure of arterial degeneration 

elasticity. The heart found connected "/ ''^e "rdi- 
•' nary type. 

with the cirrhotic kidney is always in 

the state of dilated hypertrophy usual in the senile 

heart, varying in degree in each individual case. 

Primarily this affects the left ventricle, „, , 

•^ ' The heart is 

but it is not restricted to it, and it will simply a senile 

be found affecting both ventricles, more ^'"^*" 

or less, in every case, and not merely in a matter 

1 Lectures on Pathology, by the late H. G. Sutton, M.B., 
F.K.C.P., London, 1891, p. 431, etc. 


of 70 per cent, as Buhl would have it.^ This 
dilated hypertrophy of the heart is also always 
associated with loss of elasticity and dilatation of 
the large arteries — the aorta above the valves 
averaging in circumference 7.6 cm. as against a 
normal of 6.3 cm.^ Lastly, this dilated hyper- 
trophy of the heart, as Bamberger,^ Schroetter,* 
and others tell us, always precedes the kidney 
affection. Among the scores of senile hearts 
which have come under my ovni observation, there 
have been many with cirrhotic kidneys. In 
those that proved fatal at a comparatively early 
stage the heart affection has always seemed to 
be in advance of the kidney, and in some few I 
have satisfied myself that this was actually the 

The cirrhotic kidney, as every one knows, may 
be contracted to one-half or one-third of its natural 
size; it is shrivelled, its capsule thickened and 
opaque, and its surface granular. On section the 
shrivelling is found to be chiefly at the expense of 
the cortical portion, and the cut surface is flecked 

1 Buhl, Mittheilungen aus dem pathologischen Institut zu 
Munchen, Stuttgart, 1878, S. 64, etc. 

2 This fact is noted by many authors. These figures are 
taken from Ewald, in Virchow''s Archiv., Bd. Ixxi., S. 477. 

^ Lehrbuch der Krankheiten des Herzens, Wein, 1857, S. 328. 
* Ziemssen's Cyclopedia of Practical Medicine, Vol. vi., 
p. 192. 


with streaks and specks of white from salts of uric 
acid scattered throughout the cortex and between 
the tubules. The presence of these salts in the 
stroma of the kidney has the same significance as 
elsewhere Quide antea, p. 168). It indicates a rem- 
ora of the circulation sufficient to permit those com- 
paratively insoluble salts to crystallize 
out of the lymph which floods the udney a 
tissue interspaces. This remora is due *™« aouty 
to venous congestion, the result of 
commencing failure of the central organ of the 
circulation, and is accompanied by all the usual 
consequences of venous hypersemia. One of the 
consequences of venous congestion of any organ, 
laid down by Sir William Jenner as a pathological 
law, is that the structure of any organ so con- 
gested becomes hard, tough in texture, and in- 
creased in bulk by an exudation of lymph, which 
is ultimately converted into fibrous tissue. By 
and by this new-formed tissue contracts, and if 
the organ be a kidney, its surface becomes uneven 
and granular, and cysts are developed.^ The 
structure of the kidney easily lends itself to these 
changes. The cysts are readily accounted for by 

1 Vide Medico- Chirurgical Transactions, Vol. xliii., p. 199 ; 
and Dickinson's Diseases of the Kidney, etc., Part ii. , p. 385, etc. 
Vide, also, Schmaus and Horn, Ueber den Ausgang der cyanoti- 
schen Induration der Mere in Granulanitrophie, Wiesbaden, 


the blocking off of some part of a tubule, either at 
its commencement in a Malpighian capsule, or in 
gome other part of its c6urse ; while the pyramids 
of Ferrein, even in health, present a somewhat 
granular appearance on the surface of the kidney, 
and when the septa between them are hyper- 
trophied and contracted, they must largely con- 
tribute to the well-known granular aspect of the 
cirrhotic kidney. 

Indeed, when we consider the contractions and 
deformities that disfigure the comparatively rigid 
tissues of the extremities of those suffering from 
the influence of the gouty diathesis, from the 
vascular changes upon which this diathesis is 
based, and from those which spring from it, we 
cannot wonder at the remarkable changes wrought 
in the softer and more yielding tissues of the kid- 
ney by the same means. Hypertrophy and sub- 
sequent contraction of the intra-renal fibrous 
tissue are probably sufficient of themselves to 
account for all the deformity produced, but the 
action of these causes cannot fail to be pro- 
moted by thrombosis of the vessels, which is of 
such frequent occurrence in all cases of gouty 

Gull and Sutton say : " The morbid state under 
discussion (arterio-capillary fibrosis) is allied with 
the conditions of old age, and its area may be said 


hypothetically to correspond with the ' area vascu- 
losa.' "1 A statement sufficiently con- ^ , .. 
firmative of all I have been suggesting ; capillary 
but I go a little further, and say that f™~ ««""''* 
during life it is impossible, even if it Hated during 
were desirable, to differentiate the one y^'Vata , 

' from senile 

condition from the other, and that loss of arterial 

senile loss of arterial elasticity is suffi- ^ "■^^^"^^v- 

cient to account for all those sequential changes, 

whicjh, when excessive, terminate in the gouty or 

cirrhotic kidney. 

Atherosis is merely one of those senile changes 
by which a structured matrix is replaced by 
amorphous material (vide antea, p. 13). Gout, and 
such poisons as alcohol, lead, and syphilis, promote 
the advent of this change, and the last-named 
poison is specially responsible for the end-arteritis 
so often present. But these special conditions do 
not seem to be necessary for the production of the 
gouty kidney, though undoubtedly they precipitate 
and intensify all those sequential changes which 
find their natural termination in this structural 

Sir George Johnson's uncontradicted statement, 
that the cirrhotic kidney is " of common occur- 
rence in those that eat arid drink to exceSs," ^ 

1 Medico- Chirurgical Transactions, Vol. Iv., p. 296. 
^ Medical Lectures and Essays, London, 1887, p. 680. 


sufficiently explains the predominance of hyper- 
trophy in the hearts of such patients ; while the 
fact that the cirrhotic kidney is not restricted to 
gross feeders, but is also found in those labouring 
under " certain forms of dyspepsia," ^ accounts for 
this affection not being restricted to those with 
marked cardiac hypertrophy. Every case requires 
to be considered and explained by its own indi- 
vidual circumstances. 

It must be remembered that dilatation is the 
first stage of senile cardiac failure (vide antea, 
p. 33), and even when hypertrophy afterwards 
becomes excessive, the ventricular cavity will 
always be found increased in size, though in some 
cases the mode of death makes the post-mortem 
appearance of the heart apparently to belie this 
(so-called concentric hypertrophy). 

We are told that it is always easy to differen- 
tiate the congested kidney of cardiac failure from 
the cirrhotic kidney ; because in the former case 
the urine is diminished in quantity, and there is 
a considerable amount of albumin present ; while 
in the latter case the urine is not diminished, often 
greatly increased, and the albumin is present in 
but small quantity, often only as a mere trace. 
This statement is perfectly correct, and yet in my 
own experience some indication of cardiac failure 
1 Johnson, op. cit., p. 680. 


has always preceded any manifestation of kidney 

In those rare instances in which a lifelong ac- 
quaintance with all the details of the case has 
made known every point in its history, there is 
no difficulty in ascertaining this with at least the 
highest probability. 

When, however, a case of senile heart, seen for 
the first time, presents a trace of albumin in urine 
otherwise normal as to quantity and quality, with- 
out any evident soakage of the tissues, we are not, 
perhaps, justified in regarding the kidneys as cir- 
rhotic ; but we may be well assured that only 
careful treatment can postpone, or possibly pre- 
vent, such an untoward ending. 

Having been for nearly all my professional life 
fully cognizant of the medical history of a well- 
known dignitary of a northern univer- 

(jCis& of ssHiitB 

sity, and having been for many years /,^art with 

his occasional medical adviser, I was probable dr- 

well aware that he had hard and tor- ^eys. Fatal 

tuous arteries and a hypertrophied iyuraimic 

heart, and had my eyes fully open to 

all the contingencies likely to happen in such 

a case. 

For years, however, the patient went on the 

even tenour of his way. At last, after passing his 

grand climacteric, his heart gave way : it became 


dilated, with a systolic bruit in the mitral area. 
, But not for some time after this, not till about 
four months only before the patient's death, could 
any albumin be detected in his urine. This albu- 
min never amounted to more than one-third, often 
to much less, varying from time to time, and, so 
far as I know, it was never afterwards absent till 
the end. 

The albumin came with failing health and a 
broken constitution ; the outward frame looked 
vigorous still, but the organization was giving 
way at all points, and revealing its failure in 
many ways. To an ordinary observer, it seemed 
as if the patient would be at once restored to his 
pristine vigour, if the mysterious disorder that 
sapped his strength could be recognized and re- 
moved. To the intelligent eye of the physician, 
there was but one possible ending, though it might 
come in various ways, and might be warded off 
for an uncertain period by careful and judicious 

The hard, tortuous arteries, the dilated heart, 
and the albuminous urine, told an unmistakable 
tale to a discerning mind, and in no long time 
this was emphasized by a sudden attack of blind- 
ness of one eye, due to hemorrhage into the retina 
from rupture of a vessel, as ascertained on exam- 
ination by one of our ablest oculists. 


The patient had almost constant headache, a 
feeling of intense depression, and a sensation of 
failure, pathetically revealed by a longing for a 
quiet life, and release from the burden of official 
duties ; a quietness which he scorned, and a burden 
which was unfelt in the plenitude of health, for 
in those days there were few who could compare 
with him in fulness of life and energy. Part of 
his depression was doubtless constitutional, as he 
had suffered similarly at an earlier period of life, 
but at this time there was every reason to believe 
that this constitutional depression was intensified 
by imperfect nutrition of the brain, due to arterial 
atherosis. Of this condition the hard external 
arteries, and especially the retinal hemorrhage, 
must be accepted as a sufficient exponent. 

Already the outworks were sapped, and the 
enemy was marching along the pathway of the 
arteries towards three breaches in the enceinte of 
the citadel of life — the dilated heart, the con- 
tracting kidneys, and the shrinking brain. Which 
of these would be the first to be stormed it was 
impossible to foretell. 

There was nothing to be done but to send the 
poor patient to a milder climate for the winter, in 
the hope that his valuable life might be prolonged. 
A full and particular account of his illness and 
present condition accompanied him south, and the 


programme indicated was carried out. About a 
month after I last saw him the patient died some- 
what suddenly from ursemic coma. 

This case was in every respect one of intense 
interest. What is specially noteworthy is, that 
there is an absolute certainty that the hypertrophy 
of the heart long preceded any indication of kid- 
ney affection, though this was carefully looked for 
during many years; that the kidney affection 
never became cognizable till the heart began to 
fail ; and, lastly, that this cardiac failure was 
quite unaccompanied by any other sign or symp- 
tom, apart from those of the heart itself, beyond 
the slight albuminuria; in particular, there never 
was the slightest trace of dropsy, nor any detect- 
able soakage of the tissues. 

The following case also inculcates the same 

lesson : that even when hypertrophy 

■probable, is the predominant lesion of the heart 

cirrhotic \\iq kidney affection only becomes 

fatal from cognizable when this organ begins to 

hepatic fail. 

hemorrhage. , j. j x ■ .• 

Jbor nearly forty years 1 was inti- 
mately acquainted with a gentleman, who ulti- 
mately died at the age of sixty-eight, and I had 
been his medical attendant for some considerable 
portion of that time. He was a man of robust 
frame, who lived well, and enjoyed excellent 
health up to a couple of years before his death. 


Early in life this patient's arteries became large, 
hard, and tortuous, and for quite ten years before 
his death he was known to have a large hyper- 
trophied heart, which had come on insidiously and 
presented no symptoms. About five years before 
his death his heairt began to falter and become irreg- 
ular ; it had commenced to fail. This irregularity 
was never altogether remedied, but it did not in- 
crease. During all this time the state of the kid- 
neys had been watched most carefully, but not the 
slightest imperfection could be detected, till about 
two years before the patient's death, when a small 
amount of albumin, little more than a trace, was at 
last discovered. Henceforward a trace of albumin 
was, with only rare and occasional exceptions, 
always to be found in the urine. About the same 
time, two years before his death, this patient began 
to suffer from defective memory, and to show in 
other ways a loss of brain power, of which he 
himself was painfully conscious. 

Precisely as in the former case, the enemy had 
already seized the outworks, and was marching 
along the arteries upon the citadel of life, in 
which the same three breaches had been made. 
In this case it was evident that the brain had 
suffered most, and it seemed probable that the 
breaking of the " golden bowl " would have closed 
the last scene of a most useful and energetic life. 


As it happened, this was not the case. For long 
this patient had suffered from a contracting liver 
without any marked symptoms beyond constipa- 
tion and troublesome piles ; now, however, jaun- 
dice set in, and after a few months of suffering, 
intestinal hemorrhage suddenly closed the scene. 

In this case, also, there was an absolute certainty 
that cardiac hypertrophy had for many years pre- 
ceded any manifestation of kidney disease ; the 
kidney affection never became cognizable till the 
heart began to fail ; and, lastly, this cardiac failure 
was unaccompanied by the slightest trace of 
dropsy, or of any soakage of the tissues. 

The absence of a post-mortem examination is a 
certain disadvantage in founding any argument 
upon these two cases. I think, however, that both 
Gull and Sutton would have freely acknowledged 
both as presenting well-marked clinical symptoms 
of arterio-capillary fibrosis, while I look upon them 
both as excellent examples of senile heart originat- 
ing in senile loss of arterial elasticity. 

In all such cases a gouty kidney is one of the 
possible sequential phenomena, slowly and gradu- 
ally developing itself out of the slowly increas- 
ing venous hypersemia, but never betraying itself 
by sign or symptom until, from some cause or 
other, there is some evident failure of the myo- 


Even after this the cardiac failure is so slowly 

progressive that the conditions remain 

for long practically unchanged, or they callage, as 

may even improve under treatment, well as the 

But the declension, though gradual, is of regarding 

sure, and the end comes at last, but the cirrhotic 

not always through the kidneys. One sequence of 

advantage of taking this view of the *^"*'^ 

... . , , ., . degeneration. 

gouty kidney is that the senile variety 

may be looked upon as preventible, and in the 
early stages even as amenable to treatment. The 
gouty kidney occurring before middle life is, how- 
ever, associated -with, too pronounced an arterial 
affection to be treated with success, though even 
in such a case the symptoms may be ameliorated, 
and the end postponed by judicious care. 



The heart is the one organ of the body whose 

sufferings are most apt to disturb the equanimity 

even of the most imperturbable. We know that 

with each pulsation, life and intelligence are flashed 

to the farthest outpost of our frame, and we also 

know that if the heari>beats falter for a second or 

two we fall to the ground, pale, limp, and almost 

inanimate — an almost which speedily becomes 

absolute, if from any cause these heart-beats are 

prevented from resuming their pristine vigour. 

With this knowledge ever before our eyes, and 

clinched by many a startling fact, we cannot 

wonder that feelings of alarm are ex- 
Cardiac • T 1 , . . , 
troubles al- Cited by any deviation from the nor- 

ways alarm- Qjal which makes us cognizant of the 
movements of so important an organ, 
of which we are ordinarily so profoundly un- 
conscious. Hence palpitation, intermission, irregu- 



larity, and tremor cordis, all of which make 
themselves so disagreeably perceptible to our 
senses, appeal most forcibly to the imagination 
of the patient, and bring him more certainly to 
the physician than cardiac ailments of more 
serious import but of less obtrusive character. 

Symptoms such as those described always, and 
at every age, indicate some physical impairment, a 
matter of comparatively little moment in early 
life, but of very much more serious import after 
middle life. We must not forget, too, that at any 
age, but more probably in advanced life, the 
physical impairment may be primarily due to fail- 
ure of the trophic nerve centres.^ The marked 
improvement that ordinarily follows treatment 
shows that a primary lesion of the nerve centre 
cannot be of frequent occurrence, though we may 
accept it as a possible explanation of the intracta- 
bility of some of the cases we meet with. 

Senile diseases are always degenerative, and tend 
to precipitate the natural termination of life. The 

1 " In the human body there is no mover that can properly 
he called first, or whose motion does not depend on something 
else. . . . The contraction of the heart is indeed the cause of 
the circulation of the blood, and consequently of the secretion 
of the spirits (as is supposed) in the cerebellum, etc. ; but with- 
out these spirits this action of the heart could not be performed. 
These two causes, therefore, truly act in a circle, and may be 
considered mutually as cause and effect." — Whytt, On Vital 
Motions, Edinburgh, 1751, p. 270. 


object of treatment in senile affections is not there- 
fore quite the same as in the diseases of earlier life. 
We no longer hope for complete restoration, but 
we expect to alleviate suffering, and to check 
„ , , decadence ; and so far as the heart is 

But may oe 

remedied at Concerned, we are generally able to 
any age. attain both of these objects even long 

after the average limit of mortality is overpassed. 

Many years ago a gentleman of seventy-seven 
years of age consulted me as to severe fainting fits 
to which he was liable. A distinguished consults 
ant, since dead, had told him that these attacks 
were due to fatty degeneration of his heart, and 
that no treatment would be of any avail. I found 
the heart's impulse imperceptible, the sounds faint 
but pure, the arteries firm, but neither hard nor 
tortuous ; the urine was free from albumin, and of 
average specific gravity. I explained that, con- 
sidering his age and the then state of medical 
opinion, his adviser was perfectly justified in both 
his diagnosis and prognosis, btit I added that 
experience had taught me that hearts supposed to 
be fatty, were often only weak,^ and that so serious 
a prognosis could only be justified by failure of treat- 
ment. The result of treatment in this case was 
a steady improvement in health and in force of 
heart-beat, and the patient did not die till he 
1 Balfour, op. cit., p. 309. 


attained the ripe old age of ninety, and then not 
from his heart at all, but from senile asthenia. 

In this fight with mortality, medicines have 
no doubt their place and power, but it is attention 
to the little things of daily life — the little things 
of eating, drinking, and doing — that influence the 
patient's comfort, and gradually turn the scale of 
health in his favour. Herein lies one of the great 
difficulties in the way of successful treatment, for 
when the regulations of the physician come to be 
pitted against the habits of a lifetime, there is some- 
times a difficulty in securing acquiescence. 

For several reasons {vide antea, p. 34) I have 
given the senile heart the synonym of the gouty 
heart, but the connection between the „ . . 

Two varieties 
two is more obvious at one time than of irritable 

at another. Thus, some years ago I ^^°''^*- 

used to be favoured with occasional visits from an 

elderly lady with an irritable and slightly dilated 

heart, which I told her could be best described by 

the term gouty. Then she used to turn upon me 

and say, " But Doctor this and Doctor that," for 

she was a great patron of doctors, " all say what 

does Dr. Balfour mean by saying you have a gouty 

heart, for you have no gout." To this my reply 

was, " So much the worse for you ; if you were to 

have a fit of gout, your heart would probably be 

relieved." And doubtless this would have been 


the case, quoad the irritability at least. Years 
afterwards this old lady died, and I ascertained 
that her irritable heart was due to a weakness for 
porter in excess. 

Again, I often see an old lady, hale and well 
preserved for her years, which are somewhere over 
eighty. For long this patient has had the most 
pronounced gouty heart of its kind I have ever 
seen. She has never had a regular fit of gout, but 
her fingers are all distorted with Heberden's knobs: 
she has constant dyspepsia of a well-marked gouty 
character, and she has a weak, irritable, and some- 
what dilated heart, whose most forcible attempt at 
a beat is often but a mere flutter for days at a time. 
Yet she is a sober, careful-living woman, and her 
heart responds well to treatment even at her 
advanced period of life. I have never heard a 
doubt hinted as to the nature of her complaint, 
though wonder has often been expressed at her 
apparently marvellous recoveries. 

These are opposite extremes, variants of the 
senile heart in which irritability is the prevalent 
characteristic. In the one case I wasted much 
good advice as to what to eat, drink, and avoid, 
which if attended to would have sufficed to cure 
the patient. In the other case the long-continued 
gouty dyspepsia, together with Heberden's knobs 
on her fingers, were proof enough that something 


more was required than a merely dietetic treat- 

In our dealings with senile heart affections, we 
must not forget that all cardiac affections found 

in the old are not necessarily senile 

, ^H heart 

in character, though they must' all be affections in 

unfavourably modified by the condi- '''^ °^'^ "°* 


tions present. At this moment I am senile in char- 

acquainted with a hale old gentleman, aeter or ori- 

of eighty-six years of age, who for 

sixty-six of these years is known to have suffered 

from a dilated and hypertrophied heart. 

Sixty-six years is certainly the longest period, 

in my experience, mitral regurgita- 
..111 . , Long dura- 

tion has been known or even surmised (jo„ gf g(,„g 

to exist. But I am well acquainted cardiac affec- 


with many cases in which cardiac 
disease of various forms, both mitral and aortic 
regurgitation and more rarely mitral obstruction, 
has been certainly known to exist from youth to 
age for periods varying from forty to fifty, or even 
more years, without any marked discomfort, except 
when compensation has been temporarily ruptured 
by illness. Many of these sufferers have led very 
active lives ; some of them have been members 
of my own profession, who have shirked no work 
however hard ; and it has seemed to me that the 
most active have suffered least. Possibly because 


the disease was not so serious, certainly to some 
extent because the heart is a muscular organ, 
and like all such organs is strengthened and 
invigorated by exertion not carried to exhaus- 

Irritability, with more or less of cardiac uneasi- 
ness (vide antea, p. 35), is one of the earliest indi- 
cations of advancinsr senility of the 

Earliest , ,. 

symptoms of heart. The patient conplams of an 
the senile uneasy empty feeling in the precordial 
region ; sometimes this uneasy feeling 
amounts to actual pain in and around the heart, 
but a pain strictly localized and neither shooting 
nor darting in any direction. Along with this 
uneasiness there is irritability of the heart's action, 
both as to rate and rhythm. There may be 
palpitation; rapid action; simple intermission at 
regular or irregular intervals, the heart simply 
dropping a beat occasionally ; or this intermission 
may continue during periods of longer or shorter 
duration, and may occur at longer or shorter inter- 
vals, and mostly as the result of emotion or of 
gastric disturbance; or lastly, the heart's action 
may be more or less persistently irregular as to 
rate, rhythm, and force simultaneously. 

These phenomena always indicate debility of 
the myocardium, which, left to itself, sooner or 
later leads to dilatation of its cavities, after a 


fashion already explained {vide antea, p. 40), with 
all the serious consequences which flow from this 

These sequential events do not follow a similar 
course in every case, but each follows its own 
course, according to laws which may be more or 
less easily recognized. 

One patient may for years complain of nothing 

more than an occasional soreness in 
, , . . 1111 Modes in 

the cardiac region, and at last break yjuch the 

down suddenly, from what he flatters senile heart 
1 . ,. . 1 .1 • 1 . may develop. 

himseli is only neurasthenia, but 

which turns out to be merely a commonplace dila- 
tation of the heart. This may end slowly by 
dropsical asthenia in the usual way ; not infre- 
quently it terminates in a fatal attack of angina of 
the ordinary form ; or, perhaps even more com- 
monly, in that form of sudden cardiac failure 
which may be called angina sine dolore. Another 
patient may only complain of occasional intermis- 
sion, or of fluttering of the heart, — tremor cordis, 
— which annoys him by its recurrence, and such a 
case terminates perhaps more often by an attack 
of cardiac syncope — angina sine dolore — than in 
any other way; while there are still others in 
whom intermission, irregularity, or tremor cordis 
persist for many years without any apparent detri- 
ment. In time, however, such symptoms, unless 


remedied by treatment, ultimately terminate in 
serious cardiac disease. 

Many such patients seem to suffer but little 
from their ailment; it seems somehow to escape 
their cognizance ; but there are others, not more 
seriously ill, who suffer very much from the feel- 
ing of insecurity engendered by their malady. " I 
have not gone to bed for months," said a compara- 
tively young woman to me lately, " without leav- 
ing everything as straight as possible. I feared 
each night would be my last." Yet her only 
detectable malady was a somewhat marked irreg- 
ularity of the heart's action, which was completely 
„ ^. removed after about one month's 

distwhance treatment. Then her remark to me 

apt to en- ^^^ ^j ^ ^ different character. " I 
gender feel- •' 

ings of feel quite well and young again. I 

insecurity. j^^^ ^ ^^^^ down our avenue the other 

day and felt neither breathlessness nor irregu- 

With the cardiac irregularities and intermis- 
sions of the aged there is so often a faltering of 
consciousness, or a failure of muscular power, that, 
as a rule, paralysis or brain failure is more dreaded 
than failure of the heart. Yet there is probably 
no sufferer from tremor cordis who does not feel 
inclined to exclaim with Sir Walter Scott, " What 
a detestable feeling this fluttering of the heart 


is."^ We cannot even flatter ourselves with Sir 

Walter that it is confined to the erudite — mor- 

hus eruditorum he called it — any more than we 

can nowadays limit- with Sydenham the podagra, 

upon which it depends, to the great and noble. ^ 

The senile heart is, as we have seen, a term 

which comprehends many symptoms 

, .... , . Senile 

and a variety oi signs, and is essen- cardiac 

tially a cardiac failure based upon failure 
imperfect metabolism. It is therefore i)ased upon 

of the greatest consequence to deter- imperfect 

mine the cause oi this failure by ascer- 
taining the source of the malnutrition upon which 
it depends. 

1 " I know that it is nothing organic, and that it is entirely 
nervous, but the sickening effects of it are dispiriting to a 
degree. Is it the body brings it on the mind, or the mind that 
inflicts it on the body ? I cannot tell ; but it is a severe price 
to pay for the fata morgana with which fancy sometimes 
amuses men of warm imaginations. As to body and mind, I 
fancy I might as well inquire whether the iiddle or the fiddle- 
stick makes the tune. In youth this complaint used to throw 
me into involuntary passions of causeless tears. But I will 
drive it away in the country by exercise." — Journal, Vol. i., 
p. 153. 

2 " Gout kills more rich men than poor, more wise men than 
simple. Great kings, emperors, generals, admirals, and phi- 
losophers have all died of gout. Hereby Nature shows her im- 
partiality, since those whom she favours in one way she 
afflicts in another." — Works of Thomas Sydenham, M.D., 
translated for the Sydenham Society by K. 6. Latham, M.D., 
Vol. i., p. 129. 


In all these cases the objective phenomena are 
most to be relied upon. The subjec- 

In dtacjnosti- ^j^^ phenomena, the symptoms com- 

catmg such ^ • j i- 

cases objec- plained of, are chiefly valuable as 

tivephenom- corroborating or explaining the infor- 

ena are ° . 

more to be mation derived from direct observation. 

reiiedupon -^^^^ -^^ veg2ivA. to what might be re- 

which are garded as so unmistakable a disease as 

'^^^fy angina this statement holds good (vide 

subjective. ° o v 

antea, p. 86), however trustworthy the 
patient may be. 

In examining such a case, with a view to treat- 
ment, the pulse is one of those factors 

Pulse and which requires careful consideration ; 

blood must '- 

both be rate, rhythm, and especially tension, 

carejidiy ^y\ being elements of the greatest 

examined. ° _ ° _ 

importance in formulating any opinion 

as to the exact nature of the case. If the pulse be 

small, soft, and compressible, the blood pressure is 

low, and the blood probably deficient in quantity 

(anaemia), more often defective in quality (spa- 

nsemia), as the simple anaemic condition following 

a hemorrhage speedily becomes spansemic from the 

absorption of fluid from the tissues. In such a 

case we must inquire into every possible source of 

loss of blood, every possible cause of haemolysis, 

and into every conceivable kind of interference 

with haemogenesis. External hemorrhages and 


suppurations are too obvious drains to require 

more than a mere casual mention. At 

one time one pretty free hemorrhasre ^''«*"*co- 

_ ° tions to be 

starts the organism on a downward drawnfrom 

career which there is no arresting ; at '"^ *'"'"' 

° pressure. 

another time an inconspicuous dribble 
— very often intestinal in origin — slowly and 
imperceptibly drains the life away. Into these we 
must not only inquire by interrogation, but we 
must, so far as possible, scan every part of the 
mucous tract from the nostrils to anus, and also 
investigate the nature and frequency of all the 
natural discharges, for a trifling but persistent 
diarrhoea may sap the strength and give rise to 
many anomalous symptoms; or, more insidious 
still, an excess in venery, trifling and moderate as 
it may seem, may yet come to be a serious drain 
when coupled with the impeded hsemogenesis of 
advancing age. In the early stages of many 
serious complaints which may start a senile heart 
of the most serious description a great deal of in- 
formation is to be obtained from an examination 
of the blood' itself. Thus we have an increase of 
the white cells in leucocythsemia and Hodgkin's 
disease ; the poikilocytosis of pernicious anaemia ; 
or the mere deficiency of hsemoglobin, in youth 
suggestive only of chlorosis, but in advanced life 
hinting at some obscure malignant disease. Failing 



any discoverable source of hEemolysis, or any gross 
interference with hsemogenesis, we have always to 
deal with a certain amount of dyspepsia, which is 
often a result, and not a cause, of the heart failure, 
but which always materially influences the compo- 
sition of the blood, and must, therefore, be con- 
sidered and provided for in any treatment which 
is to prove effectual. 

If, on the other hand, the pulse is firm, hard, 
wiry, and full between the beats, this indicates an 
abnormally high blood pressure. That is the name 
we give to the condition; the fact that underlies 
this, and which is really what is indicated, is that 
^ -. ,. the blood does not pass so freely as 

Indications ^ •' 

to be drawn it ought from the arteries into the 

fromt e ycins. This condition of pulse may 

presence of a sr j 

high blood coexist with any of the conditions just 
pressuie. referred to, and this additional ele- 

ment in no ways makes unnecessary our enquiry 
into the state of the blood itself. 

The normal loss of arterial elasticity, which ac- 
companies advancing years, of necessity increases 
peripheral friction, raises the blood -pressure, and 
thus increases the work of the heart (vide antea, 
p. 13). Under the influence of rheumatism, gout, 
or of such poisons as alcohol, lead, or syphilis, 
frequently accompanied by acute or chronic in- 
flammation of one or other of the arterial coats, 


or of all three, the arteries get converted into 
hard, often ringed and rigid, tubes, whereby their 
elasticity is still farther diminished, and the work 
of the heart much increased. Normal nutrition 
is quite sufficient to maintain the heart intact 
under ordinary circumstances ; but any interfer- 
ence with the nutrition of the heart on the one 
hand, or any considerable increase of its work on 
the other, disturbs the equilibrium, and the heart 
becomes irritable, and it may be irregular in its 
action, and slowly dilates. On the other hand, 
if a similar call for exertion on the part of the 
heart is accompanied by a superabundant supply 
of food and stimulants, the primary 
dilatation! is speedily followed by ;l"^*f««" 

>: J -i heart by 710 

considerable hypertrophy of the left means idio- 

ventricle, and we have established the ^"^^'^^ '" *'"' 
' ongm. 

'i luxus " heart of the Germans. This 
hypertrophy of gourmands is described by Traube 
and Fraentzel as due to luxurious feeding alone ; 
but, as Cohnheim has wisely said, " To an accurate 
comprehension of the manner in which supera- 
bundant meals increase the work of the heart, 
the physiological data at our command are inade- 
quate." 2 There is, in truth, no fact in physiology 
that teaches us that excess of nutriment promotes 
cardiac hypertrophy. There is no hypertrophy of 
1 Cohnlieim, op. cit., p. 66. 2 Colmlaeim, op. cit., p. 67. 


the heart among the Strassburg geese stuffed to 
repletion to supply the market with foie gras, nor 
did any one ever hear of a young porker, fattened 
for the butcher, having enlargement of the heart. 
As an initiative, there must first be peripheral 
obstruction, so that the heart, being "more than 
usually exercised in its office," ^ hypertrophies. If 
the call for extra exertion is only imperfectly 
responded to, because the heart is ill nourished, 
irritability and dilatation of the myocardium 
speedily follow. But if the obstruction is consid- 
erable, and the blood-supply abundantly nutritious 
and stimulating, hypertrophy follows. Both pro- 
cesses progress slowly and gradually; but the 
irritability of a weak dilating heart very soon 
attracts attention to itself; whereas, a hypertro- 
phied heart gives rise to but few symptoms, and 
is apt to be overlooked and only discovered acci^ 
dentally, until it begins to fail. A heart in which 
the left ventricle is hypertrophied, with a hard, 
firm pulse indicating increased intra-arterial blood 
pressure, is often looked upon as renal in its origin, 
because frequently found associated with cirrhotic 
kidneys (vide antea, p. 200). It is, however, much 
more probably primary, and the cause of the kid- 
ney affection, not its result (vide antea, p. 202). 

1 Lectures on Surgical Pathology, by James Paget, F.E.S., 
etc., London, 1870, 3d edition, p. 49. 


Even in young and healthy arteries any increase 
of the blood, pressure over the normal mean pro- 
duces rigidity of the arterial walls.^ In advanc- 
ing age, therefore, as the arterial walls become less 
elastic, a comparatively trifling rise of the intra- 
arterial blood pressure suffices to make the arterial 
coats tense and rigid, the artery rolling like whip- 
cord beneath the finger, while the trifling charac- 
ter of the pulsatile movement, coupled with the 
considerable pressure required to arrest it, suffi- 
ciently indicate the nature of the obstacle to the 
ventricular output, and the consequent embar- 
rassment to the heart's action. An embarrassment 
of this character occurring during the night is a 
common cause of cardiac asthma, and evidently 
many deaths from angina sine dolore, whether by 
day or night, are due to this cause, happening as 
they so often do when the patient is at perfect 
rest. The spasm of the arterioles, which in such 
cases is the cause of the rise of the blood pressure, 
may be reflex from the stomach, intestines, or some 
other organ ; or it may be due to direct irritation 
of the vaso-motor centre in the medulla. There 
is even reason to believe that at times the rise of 

1 "70 or 80 mm. of mercury is about the normal mean 
blood pressure of the rabbit, and this experiment shows that 
above this the arteries become more and more rigid- walled." 
— Eoy and Adami, Practitioner, 1890, p. 351. 


blood pressure may be due to increase of the ven- 
tricular output from cardiac stimulation, and there 
is no reason to doubt that cardiac stimulation 
coupled with contraction of the arterioles is a v6ry 
frequent cause of this rise of the intra-arterial blood 
pressure. A great effect in this respect is usually 
accorded to the kidneys ; this, however, can only 
be partially tenable, as it is only universally appli- 
cable in the case of the cirrhotic kidney, and in 
that affection there is sufficient reason for the rise 
of blood pressure apart from any affection of the 
kidney, which it indeed precedes {vide antea, p. 



When any one past middle life complains of 
symptoms resembling those described as associated 
with the senile heart, we know that, whatever else 
there may be, there certainly is failure of the 
myocardium. In such a case our first endeavour 
must be to discover and remove any possible cause 
of enfeeblement, whether that be an obvious drain 
or merely a constructive one, nervous exhaustion 
following overwork or worry. And our next 
endeavour must be to build up and energize the 
frame generally, and the heart in particular. Exer- 
cise, diet, and inedicines are the three agents em- 
ployed to this end. 

Medicines are indispensable in restoring the 
vital balance of an organism that has been lost 
through failure of an organ, especially if that 
organ be the heart. 

Exercise and diet are, however, paramount in 


maintaining the integrity of a healthy organism ; 
and, properly employed, they are also of the 
greatest value in restoring it when lost. 

It seems somewhat of a paradox to speak of 
exercise as a treatment for an organ 


in the treat- which takes its needful rest in sec- 
ment of the tions, and that only for fractions of a 

senile heart. . , i i • i i i - . 

mmute, and which, as a whole, is in 

constant and continuous work from man's birth to 
his death. Yet we know that, like every other 
muscular organ, the heart is strengthened by 
exertion, and that if well fed, it hypertrophies 
when that is in excess. The rational deduction 
from this is that exercise judiciously employed 
may be profitable to the strengthening of a weak 
heart. Stokes was the first to point out this. He 
recommended graduated exercise as useful in the 
treatment of those weak hearts which he believed 
to be the subjects of fatty degeneration ; ^ and from 
a personal reminiscence of von Ziemssen we learn 
that Stokes also employed exercise in the treat- 
ment of valvular lesions, and specially insisted on 
the value of even violent exertion in the treatment 
of aortic regurgitation .^ Of late years Oertel has 
done good service in directing the attention of the 

^ Diseases of the Heart and Aorta, Dublin, 1854, p. 357. 
'^ Verhandlungen des Congresses fiir Innere Medicin, Wies- 
baden, 1888, S. 55. 


profession to the importance of regulated diet and 
exercise in the treatment of cardiac affections. 
Much benefit has doubtless followed the recogni- 
tion of the fact that the discovery of a cardiac 
murmur is not a signal for a carrying chair, and 
need not be looked upon as a bar to moderate 
exertion. Yet, though aortic regurgitation is not 
always found to be a bar to even violent exertion, 
no one, I think, would be inclined to treat it, as 
Stokes is said to have done, by setting the sufferer 
to run behind his own carriage. ^ Eegular, mod- 
erate exertion helps to keep the myocardium well 
nourished, whatever goes beyond tends to promote 
■hypertrophy; and as the coronary arteries have 
only a limited feeding power, when the myo- 
cardium gets beyond this, irremediable failure in- 
augurates the end under various symptoms. Nor 
is this the only risk ; for long-continued exertion, 
especially if violent, is, we know, liable to be fol- 
lowed by muscular collapse, and what this means 
to a heart it is not difficult to imagine. More- 
over, scarcely a day passes in which the danger 
of irregular exertion is not exemplified by the 
sudden death of some one hurrjdng to catch a 
train or a 'bus — a death which often puts a sud- 
den termination to the useful lives of those who 
had never been known to ail, although they had 
certainly begun to age. 

1 Loo. ait. 


When, however, the compensation is only in- 
complete, when exertion, even though 
however, slight, brings on dyspnoea, even if 

absolutely ^-^^^^ ^^ ^^ evident soakage of the 

paramount '^ 

in certain tissues, and still more if there is, then 

cases. exercise, even though carefully gradu- 

ated, ought to form no part of the treatment : the 
risk is too great. Rest, diet, and heart tonics will 
suffice, if it be at all possible, in time to restore 
the compensation, and then exercise may be hope- 
fully resorted to as an adjuvant, but it must be 
begun cautiously and continued with care. In a 
great many cases of senile heart, intermission and 
irregularity are entirely reflex in character, and 
are not increased, but rather relieved, by exercise, 
the effect of which is to lower the blood pressure,^ 
and thus to promote the fulness and freedom of 
the heart's contraction, as well as its force and 
vigour. The exercise not only benefits the heart 
at the time, but by promoting the circulation 
through its walls it nourishes the muscle and 
accumulates energy within the ganglia. This, 
however, can only happen when the organism is 
not enfeebled, and when the heart itself retains 

1 Vide Foster's Physiology, fifth edition, p. 148 : " At the 
time of contraction more blood flows through the muscle, and 
this increased flow continues for some little time after the con- 
traction of the muscle has ceased." 


sufficient recuperative power, and is more op- 
pressed than debilitated. The greater freedom of 
respiration and of circulation resulting from exer- 
cise makes metabolism more perfect, and thus 
favourably influences the manufacture of urea in 
the liver, and promotes the depuration of the 
blood. Thus, in appropriate cases, not the heart 
only, but the whole organism, is the better for 

In most cases of senile heart, however, rest 
will be found the most generally applicable 
treatment, and when palpitation, irregularity, or 
breathlessness follows exertion, rest is the treat- 
ment to which — at first, at all events — we are 

The question of exercise must always be care- 
fully considered in relation to each special case, 
and thereafter adapted and regulated in accord- 
ance with its requirements. But, while in regard 
to the relief of symptoms the question of exercise 
always requires careful consideration, there is no 
doubt whatever that as a preventative of many of 
the evils associated with the senile heart it holds a 
most important place ; not the foremost place, nor 
the paramount position, for that belongs to tem- 
perance alone, which even without exercise can 
maintain health, if it cannot bestow strength nor 
ensure longevity. Of this a late eminent physi- 


cian was a notable example, and there is not one 
of us who cannot call to mind many similar in- 

Temperance — moderation in all things — is the 

true secret for preserving a mens sana in corpore 

sano ; and if it be not a certain pass- 

importance of ^^ ^ longevity, it at least enables 

temperance. -"^ o j ' 

' us to live healthily for as long as 

we may. In these fin de siecle days, when every 
doctrine is a fad and gets pushed to an ex- 
treme, there are multitudes eager to enforce a 
rabid teetotalism upon all their fellow-men as the 
only panacea for health, happiness, and longevity. 
But if we except the votaries of vegetarianism, 
which is more of a cult than a protest against 
excess, I know of no society that inculcates, by 
precept or example, temperance in regard to food ; 
yet there is nothing ages a man or a woman so 
rapidly, there is nothing that shortens life so 
certainly, and there is nothing that embitters the 
latter days of life so much as over-indulgence in 
food. To those who can afford thus to transgress 
— to the well-to-do — excess in food is a much 
more serious menace to health and life than excess 
in drink, and it is specially so in respect of senile 
affections of the heart, some of which have been 
distinctly recognized to owe their origin to over- 
indulgence, while all are distinctly aggravated 
by it. 


All those who after, middle life complain of 
cardiac symptoms require to be dieted y^^^^^ ^-g. 
for some reason or other ; the condi- twrws may be 
tion of the patient and his leading '■^2«»''e • 
symptoms supply the indications for which we 
have to provide. 

The larger number of such patients are either 
at their normal weight or slightly below it ; they 
often suffer very considerably from intermission 
or irregularity of the heart's action, with breath- 
lessness on exertion. These require careful regu- 
lation of a normal dietary presently to be specified. 
A smaller number are over their normal weight, — 
obese, — and suffer more from breathlessness and 
less from irregularity than the preceding class of 
cases. These require to be specially dieted and 
cared for, so as to remove the obesity without 
diminishing the cardiac energy or the strength 
of the myocardium. Lastly, we have those in 
whom there is more evident failure of the myo- 
cardium. There may not be so much trouble from 
intermission and irregularity, but the signs of 
cardiac dilatation are more marked than in either 
of the preceding classes of cases, and there . are 
more or less evident indications of soakage of the 
tissues. Such cases require to have a specially dry 
diet prescribed for them. 

In all cases where diet and dietaries come into 


question, the first point of importance is to divide 

the day properly, so that there may 

Number of Y)e a sufficient interval between the 

meals and ' 

length of meals. This is a matter of absolute 
interval be- necessity to secure perfect digestion. 

tween them. •' . 

Three things greatly disturb gastric 

comfort, — too large a ineal, too short an interval 
between the meals, and, lastly, the ingestion of 
food into a stomach still digesting. If the heart 
is weak, the discomfort induced by such irregu- 
larities is, after middle life, more apt to be felt in 
connection with that organ than in the stomach 
itself. In health, the stomach empties itself in 
from three to four hours after the ingestion of a 
meal, and requires an hour's rest before a further 
supply is introduced. In those with weak hearts 
and feeble circulations, the digestion is necessarily 
somewhat slower ; hence the first rule to lay down 
is : There must not be less than five hours between 
each meal} This allows of three meals in the day, 
with a sufficient interval after the last meal to 
permit its digestion to be well advanced before 

1 Abercrombie says : "If digestion goes on more slowly and 
more ' imperfectly tban in the healtby state, another impor- 
tant rule will be, not to take in additional food until time has 
been given for the solution of the former. If the healthy period 
be four or five hours, the dyspeptic should probably allow six 
or seven." — Pathological and Practical Hesearches on Dis- 
eases of the Stomach, London, 1837, 3d edition, p. 72. 


retiring to rest, which tends to ensure a quiet and 
restful night. The next matter of importance to 
remember is, that the ingestion of solid food into 
a stomach still engaged in digesting a former meal 
arrests the process and provokes the formation of 
flatulence ; hence the second .rule to be laid down 
is : No solid food of any hind is to be taken between 
meals. This rule is absolute ; not a morsel of 
cake, or of biscuit, or any similar trifle, is to be 
ingested between meals. There is nothing so 
destructive of gastric comfort as the continual 
pecking induced by gouty bulimia. This prohi- 
bition does not extend to fluids, which, taken hot 
about three or four hours after a meal, often start 
afresh a flagging digestion, wash the remains of 
the meal out of the stomach, and so prepare that 
organ for its needed rest. 

The third rule to be remembered is : All inva- 
lids should have their most important meal in the 
middle of the day. They should only have a 
light meal in the evening. 

AU those with weak hearts have feeble diges- 
tion, because the gastric juice is both deficient in 
quantity and defective in quality. It is needful, 
therefore, in many cases, to restrict the quantity 
of the food, and in all to see that it is not diluted 
with too much fluid. Hence a fourth rule of 
much importance for the comfort of cardiac in- 


valids is : Ml those with weak hearts should have 
their meals as dry as possible} 

These four rules are of great importance for all 
dyspeptics ; but for the comfort and relief of those 
with weak hearts they must be strictly attended 
to. It may be well to recapitulate them. 

1. There must never be less than five hours be- 
tween each meal, 
feeding those 2. No soUd food IS ever to be taken 
with weak between meals. 

3. All those with weak hearts should 
have their principal meal in the middle of the day, 

4. All those with weak hearts should have their 
meals as dry as possible. 

A weak heart means feeble digestion; delay in 
digestion makes all food, and specially certain 
kinds of foods, prone to ferment and to break up 
into injurious acids and gases. Undigested food, 
acids, or gases in the stomach inhibit a weak heart 
through the pneumogastric nerve, and gives rise 
to intermissions, irregularity, tremor cordis, etc. 
It is of consequence, therefore, to knock out of 
the dietary of such patients everything likely to 
be difficult of digestion, such as salted, dried, or 

1 " In affections of the heart the most remarkable change in 
respect of digestion is the slowness with which liquids are ab- 
sorbed by the stomach." — A Manual of Diet in Health and 
Disease, by Thomas King Chambers, M.D., Oxon., etc., Lon- 
don, 1875, p. 341. 


otherwise preserved meats ; cheese ; pastry, and all 
similar foods in which fatty matter , ^. , 
has undergone prolonged exposure to of food 
heat ; all sweets ; and nuts, which ™««f«6'^ 

for those 

contain a quantity of oleaginous mat- with weak 
ter prone to become rancid by keep- ''^'"''''• 
ing. Vegetable food is more apt to give rise 
to flatulence than animal, and all articles belong- 
ing to the cabbage tribe are specially objectionable 
in this respect ; but such roots as carrots, turnips, 
and parsnips are not much better. Even potatoes 
require to be used sparingly.^ Fruits possess a 
low nutritive value, but when suitable they form 
pleasant and agreeable articles of diet when taken, 
as on the Continent, as a meal, such as breakfast, 
or as part of the mid-day meal, but they are apt to 
be hurtful when introduced as a mere addendum 
or dessert. 

In treating dietetically those with weak hearts 
no good is to be gained by attempting to enforce 
rigid dietetic rules, founded upon the number of 
grains of carbon and of nitrogen required for 
carrying on the operations of life. We have to 
consult with our patients as to what can, rather 
than to lay down the law as to what ought, to be 
taken, keeping always the right of veto in our 
own hands, as in many of these cases gouty 
bulimia, and long perseverance in unrestrained 


indulgence, have depraved the appetite, and 
vitiated its right of selection. 

With due regard to idiosyncrasy, therefore, 

which must always be respected, we 

diet suitable select for such cases such white fish as 

for those with whiting, haddock, skate, sole, or plaice, 

weak hearts. . . , . . , 

rejecting the coarser varieties, such as 
cod, etc. We also recommend meat with short 
fibre, such as chicken, rabbit, game, mutton, or 
well-grown lamb, in preference to such meats as 
beef, whose fibres are long and tough. As few 
people enjoy dinner without a potato, one well- 
boiled, ripe, and mealy potato may be permitted, 
but no more. Beyond that the only perfectly safe 
vegetable is spinach, in which there is not a particle 
of flatulence; but asparagus, leeks, onions, and 
tomatoes may be taken in moderation if desired. 
Peas, beans, and other leguminous seeds tax the 
powers of digestion, and must be partaken of 
sparingly. On the other hand, such seeds are 
highly nutritious, and in their green state sapid, 
and may be used in moderation without dis- 
advantage ; the object of having a variety not 
being to stimulate to excess, but to be able to re- 
place one suitable article occasionally by another, 
even animal food being often very advantageously 
replaced by fruit or vegetables. 

Some people have a difficulty in taking their 


food without some fluid, but this must always 

be restricted to the smallest possible 

, „ Fluids at 

quantity, never more than live ounces mealtimes 

with any meal, and if possible less, must always 
If water be taken with the meals, it 
should be sipped as hot as possible ; if tea, as at 
breakfast, it should not be stronger than one 
spoonful, 100 grains, to the five ounces, and in- 
fused not longer than three minutes ; coffee may 
be made to taste, and taken either noir or au lait. 
Chocolate and cocoa are too much of foods for 
those with weak hearts, but they may occasionally 
be useful if taken alone, or with a bit of dry toast 
only ; on the other hand, the infusion of cocoa 
nibs makes a beverage closely analogous to tea 
and coffee, but of a milder and less stimulating 
character, and therefore more suitable for many. 
Alcohol is not a food for the heart, and should 
never be prescribed, except pro re nata ; but so 
many of our patients have been lifelong imbibers 
of alcohol in some form or other that we can 
usually only restrict and not altogether prohibit. 
For those, then, to whom alcohol is permitted, 
half an ounce of whisky, brandy, or gin may be 
given in three or four ounces of water twice a day, 
along with food ; or a single glass of port or sherry, 
or a couple of glasses of any lighter wine, such as 
hock or claret : each glass to measure two fluid 


ounces ; and the stronger wines are restricted be- 
cause liable to give rise to acid dyspepsia if taken 
in larger quantity. For the same reason cham- 
pagne is absolutely forbidden as a rule. But there 
is so much idiosjTicrasy in the action of wines that 
each case must be arranged for separately. The 
only safe form of alcohol, if such a thing can be, 
is pure whisky and water in extreme moderation. 
Small quantities of alcohol are frequently pre- 
scribed as an ordinary stimulant for a weak heart, 
to be taken repeatedly during the day. This is a 
most injurious treatment, as, though the primaiy 
effect of the alcohol is stimulating, it depresses 
secondarily. In ordinary circumstances it is much 
better to direct such a patient to take two or 
three sips of hot water, as hot as can 

Sipping hot ijg swallowed, occasionally throughout 

water an ' j o 

excellent the day; this will be found to have 

stimulant for -^ ^ ^j ^^ immediate effect upon 

a weak heart, x o r 

the heart as alcohol, as I have been 
assured by those who have tried both, while it is 
entirely without any secondary ill results. 

While desirable to keep the meals of those with 
Fiudsin weak hearts as dry as possible, it is 
moderation equally needful that a sufficiency of 

TZv'taken ^""^^ ^^^^^^ ^ ingested to maintain 
between metabolism and keep the secretions, 

™®"^*" especially those of the skin and kid- 


neys, in good working order. The daily allow- 
ance of fifteen ounces permitted to be taken with, 
the food, together with the amount of water con- 
tained in the food itself, will be found to be quite 
sufficient to provide for all the necessary tissue 
changes. But if thirst be complained of, half a 
pint of hot water may be sipped about four hours 
after each meal, or only after the principal meal ; 
this will wash all the Mhris and refuse acids out 
of the stomach and prepare it for its rest. Taken 
thus, on an empty, or nearly empty, stomach, 
water is readily absorbed, passes straight to the 
kidneys, and is not liable either to raise the blood 
pressure or to embarrass the heart, if taken in 
moderation. Hot water, as hot as can be sipped, 
quenches thirst much better than cold, which is 
of little avail. Small bits of ice to suck are also 
useful, but the tepid water resulting from the 
melting ice must be spat out, as, if swallowed, it 
sickens. It is often agreeable for such thirsty 
souls to suck a slice of lemon, and they find it 
useful. After all, thirst usually depends upon the 
catarrhal dyspepsia so commonly present in all 
such cases, and it ceases shortly after the dietary 
has been carefully regulated. 

To relieve a weak heart, we must not only keep 
the meals dry, but it is also needful to limit the 
quantity of solids. For many years I have been 


in the habit of prescribing the following dietary, 

as one useful to begin with, generally 

solid food to sufficient, and which can be easily 

be allowed. j^jodified if this be found needful: — 

Breakfast., 8.30: One small slice of diy toast, 
weighing about an ounce and a half, with butter ; 
one soft-boiled or poached egg, or half a small 
haddock, or its equivalent in any other fresh white 
fish ; with from three to five ounces of tea or 
coffee, with cream and sugar. If there be any 
difficulty about the tea, it may be replaced by 'a 
similar quantity of infusion of cocoa nibs, or milk 
and hot water, or cream and seltzer water. Some 
prefer oatmeal porridge, with milk or cream, 
and in ordinary circumstances this need not be 
objected to, provided not more than four or five 
ounces of milk be taken, and the porridge be not 
more in quantity than three or four ounces of oat- 
meal, well boiled; provided, also, that porridge 
alone be taken, and not porridge first, followed by 
tea, toast, etc., which is destructive of all comfort, 
both for stomach and heart. 

The principal meal of the day, whether it is 
called luneh or dinner, should be taken about 1.30 
or 2 o'clock, and may consist of two courses, not 
more — fish and meat, or fish and pudding, or 
meat and pudding. Soups, pastry, pickles, and 
cheese are absolutely forbidden. White fish and 


meat with short fibres are preferred. Half a 
haddock, or its equivalent in any other white 
fish, boiled in milk, steamed, or broiled, never 
fried; wing and part of the breast of a chicken, 
or its equivalent in sweetbreads, tripe, rabbit, 
game, or mutton ; one single potato, or a little 
spinach. For pudding, any form of simple milk 
pudding may be taken, or about half a pound 
of such fruits as pears, apples, grapes, etc., either 
cooked or uncooked. During this meal four 
or five ounces of hot water may be sipped if 

From 5 to 6, three or four ounces of tea may be 
taken if desired, infused as in the morning, not 
longer than four minutes, and with cream and sugar 
if wished ; but no solid food must be taken with it, 
not even a morsel of cake or biscuit. If there be 
any difficulty about the tea, four or five ounces of 
hot water may be substituted for it, and if there 
seem any need for a stimulant at this time, a tea- 
spoonful of Liebig's extract of beef may be stirred 
into it. 

"Supper, or the last meal of the day, must always 
be a light meal. It should be taken about 7, and 
may consist of white fish and a potato, or toast, 
with butter, or some milk pudding, or bread and 
milk, or Revalenta, made with milk or with Lie- 
big's extract of beef. At bedtime, four or five 


ounces of hot water will soothe the stomach, pro- 
mote sleep, and pave the way for a comfortable 
breakfast next morning. 

On such a dietary a weak digestion from a 
feeble heart will gradually recover its tone, and 
the patient will feel comfortable, instead of being 
puffy and oppressed after meals, with an irregular 
and tumbling heart. The patient usually loses 
weight at first, from the circulation recovering its 
tone and reabsorbing the (edematous soakage, 
which, spread over every interstice of the body, 
often amounts to a good few pounds before it 
makes itself in any way perceptible as a localized 

Those who have been slowly wasting from im- 
paired digestion gain flesh from the improve- 
ment in this function, while an obese person 
gets thinner, from the cutting off of excesses 
and the diminution of the fluid taken with each 
meal.^ In both an equilibrium is established as 
soon as the average normal weight is reached. 
Should this not be the case, we must first ascer- 
tain that the dietary has been strictly followed, 
and then proceed to alter it in the necessary 

1 By means of a similar dietary the patient -whose pulse 
tracing is given at Fig. 4, p. 49, was brought down comfortably 
from over 20 stone to under 14 stone, in spite of his dilated 


direction. If the patient has been losing flesh 
too rapidly, the diet must be made more nutri- 
tious ; this is seldom required. On the other . 
hand, obesity may be slow in decreasing, and this 
will only require a little more self-denial, espe- 
cially as to fluids. A mixed diet is always best 
for the maintenance of health, and if animal 
fats are not too much indulged in, the carbo- 
hydrates in the diet indicated will not be found 
too much. 

Those who are above the normal weight, and 
are troubled with breathlessness, or other symp- 
tom referrible to the heart, are often set down as 
having fatty hearts, and no doubt they have of a 
kind. A heart is said to be fattily degenerated 
when the protoplasm of the fibres composing its 
myocardium becomes converted into fatty granules 
by retrograde metamorphosis due to defective nutri- 
tion. This arises from various causes ; it occurs in 
connection with fevers, and other diseases, such as 
pericarditis, etc. It is chiefly of importance in 
connection with the senile heart, because it is so 
often found in connection with athero- 

T J. ,1 , . Diagnosis of 

matous disease ot the coronary arteries, ^fg^^^y J^^^^^_ 
and associated with angina. It is ab- 
solutely impossible to diagnosticate fatty degenera- 
tion of the heart ; we may surmise its existence, 
but we can only be certain of its presence when 


we see it fost mortem^ We are often told that 
there is danger in treating a fatty heart, as forci- 
ble excitement of the healthy part of the fibre 
might tear it from its connection with the dis- 
eased portion. But a dread of this kind would 
hamper us sadly in the treatment of weak, di- 
lated, aged hearts, as the signs and symptoms 
which those present are precisely those upon 
which we are told to rely in diagnosticating a 
fatty heart. 

At page 216 will be found narrated the case of 

an old gentleman of seventy-seven, 

supposed whose heart was diagnosed to be fatty 

fatty heart. ^^ ^^^ ^f ^^^ ^^^es^ observers of his 

day. Yet the result of treatment was a cure, 
proving that a heart supposed to be fatty was 
only weak, and that a life supposed to be over 
qnly wanted the fillip of a few minims of digitalis 
to carry it on to almost the extreme of human 

1 "Die einfache Erfahrung, dass man in vielen Fallen von 
Herzdilationen mit starker TJnregelmassigkeit des Pulses bei der 
Section oft nur eine sehr geringe oder gar keine Fettmetamor- 
ptiose findet, wSlirend schwere Verfettungen der Muskelatur 
ohne alle Symptome von Seiten des Herzens verlaufen konnen, 
die Erfahrung also dass die Muskelverfettung nicht in directen 
Verhaltniss zur Schwere der klinischen Symptome steht, zwingt 
uns ein hesonderes Krankheitsbild 'Fettherz' aufzugeben." — 
Fraentzel, Die idiopathische Serzvergrosserung, Berlin, 1889, 
S. 191 ; also Balfour, op. cit., pp. 309 and 348. 


In true fatty degeneration no benefit can be ex- 
pected from treatment, but I have never seen 
any detriment follow treatment, even when the 
heart was ultimately found to be actually fattily 

There is, however, still another form of fatty 
heart in which treatment may be of the greatest 
possible service, or the reverse, accord- 
ing to its character. I refer to those trmtZlt xT 
who are obese, whose hearts are op- a^iposUas 


pressed with fat, overlying the base 
and infiltrating the myocardium as an adipositas 
cordis, the muscular fibres themselves remaining 
healthy. These hearts are usually somewhat 
dilated and hypertrophied, occasionally intermit- 
tent or irregular in their action. Careful dieting, 
cardiac tonics, rest at first, and regulated exercise 
subsequently, speedily improve these hearts. But 
obese, gouty, and breathless, without marked 
cardiac disturbance, these are just the cases apt 
to get sent off to some Spa, such as Marienbad, 
Kissingen, or Tarasp, to get dieted and washed 
out, often with the most disastrous results,^ the 
treatment usual at such Spas precipitating and 
increasing the dilatation it is our object to avert 
or remedy. 

1 Vide Edinburgh Medical Journal, January, 1890, p. 607 ; 
and Fraentzel, op. cit., S. 102. 


When there is anasarca, or any evidence of 

A perfectly soakage in any depending part of the 

dry diet of body, it is of the greatest importance 

great irtv- . ^^^ patient, for a time at least, 

portance when jr r ' 

adema is on the driest possible diet, and not too 

present. ^^^^ ^^ .^_ ^j^.^ -^ g^rried out by 

allowing for — 

Breakfast : One single slice of dry toast, weigh- 
ing about an ounce and a half, with no butter, 
but with a single cup of tea infused not longer 
than four minutes, with cream and sugar, amount- 
ing in all to not more than four ounces ; and 
nothing else. 

Dinner : Not more than the lean of two chops, 
or its equivalent in chicken or fish ; no vegetables ; 
as much dry toast as may be desired ; half an 
ounce of brandy, whisky, or Hollands, in three 
ounces of water ; and nothing else. 

Supper: As much dry toast may be taken as 
is desired, along with half an ounce of brandy, 
whisky, or gin, in three ounces of water ; and 
nothing more. 

It is not very desirable that a patient in this 
condition should drink much, even between meals, 
but, if thirsty, the patient may be permitted to sip 
slowly three or four ounces of hot water about 
an hour before each meal. 


The relief obtained by this strict diet is both 
remarkable and immediate ; I have seen a con- 
siderable amount of oedema of the lower limbs 
disappear within twenty-four hours, before there 
had been time for any change in the heart, which 
was feeble and dilated. 

Most of our patients have been very self- 
indulgent, and are prone to assail us with loud 
complaints of being starved. They scarcely realize 
that both life and comfort depend upon strict 
adherence to the regulations laid down, and even 
while benefiting by the diet, are anxious to have 
the rules relaxed. " O doctor," said a lady whose 
feeble, irritable heart had long been a trouble to 
herself and me, " I have no heart now ; mayn't I 
have a scone to afternoon tea?" "Certainly, if 
you wish it, but you will suffer for it." " Ah," 
she said, " I know that, for I have tried it." As 
to the starvation part of the matter, there have 
been .so many exhibitions of fasting men of late 
years, that for the first week or two even the most 
unreasonable may be easily controlled. By that 
time our point will have been gained, and the 
improvement will be so great that we will scarcely 
require to appeal to the experience of Luigi Cornaro. 
This Venetian gentleman of the seventeenth cen- 
tury, after a youth of excess which destroyed his 
health, restored himself, after the age of forty, to 


perfect health by a most rigid diet. Cornaro re- 
stricted himself to a daily allowance of 
Cornaro's bread, meat, and yolk of egg, amount- 
which he lived ing to twelve ounccs in all. With 
in health for j^ ^^^-^^ ^^ ^^^^ ^^-^ fourteen 

sixty years. 

ounces of a light Italian wine each day. 

Upon this abstemious diet Cornaro lived in perfect 
health, both of body and mind, for more than sixty 
years, dying at last at the age of over one hundred 
years.^ The only illness recorded after the adop- 
tion of this hermit fare was due to an excess of a 
couple of ounces in the day, both of solids and of 
fluids, which Cornaro was persuaded to indulge in 
at the instigation of friends, but to his own serious 

We must always, however, blend judgment with 
knowledge, and by occasional weighing, see that 
our patients do not lose weight too rapidly, and 
that they maintain an equilibrium when the normal 
has been gained. Should weight under such cir- 
cumstances still continue to be lost, enquiry must 
be made, and, if needful, some change made in 
the dietary. 

Tobacco is so much used nowadays that any 
system of dietary would be incomplete which took 

1 Sure Methods of Attaining a Long and Healthful Life. By 
Lewis Cornaro, London, 1820, 23d edition, p. 32. 
^ Cornaro, loc. cit. 


no note of this. Snuffing and chewing are both so 

little used, in this part of the world at 

least, that nothing need be said of ^;/°"'«"'^« 
° of tobacco, 

either. Smoking tobacco is so common 
a habit, and one so often indulged in to excess, 
that some rules seem requisite by which the habit 
may be regulated. First of all, it may be noted 
that the prevalent habit of cigarette-smoking and 
inhaling is the most seductive as well as the most 
injurious method of using tobacco, besides being a 
habit which seems most difficult to break. The 
only benefit ever claimed for tobacco — as a lux- 
ury — is that in some it soothes, and removes 
exhaustion, listlessness, and restlessness, when 
these are brought on by mental or bodily fatigue. 
But there are many who experience no such effect, 
and who have no excuse for the habit save imita- 
tion in the first instance and the force of habit 

Tobacco is a most potent narcotic poison ; in 
excess it may cause sickness, vomiting, y^j^g^^ ^^^^ 

and sometimes prolonged lethargy ; its dangerous to 

,11 ,• ijj.i_ T.a weak heart. 

action on the heart is exerted through 

the vagus, which it first stimulates and then para- 
lyzes. The stomach and brain are most apt to 
be affected by tobacco when swallowed ; smok- 
ing chiefly affects the heart. At universities 
and schools of medicine, where young men con- 


gregate and teach each other the habit of smoking, 
there is always ample opportunity of studying the 
effect of tobacco on the heart. The tobacco heart 
is neither a functional nor an organic complaint; 
it is an acute or chronic poisoning of the vagus, 
which may lead to actual dilatation of the heart, 
and even to death itself. The tobacco heart is 
revealed by many vagaries, from an acute attack 
of intermittence, following prolonged smoking, 
and disappearing in a few hours, to prolonged 
irregular action, violent tachycardia, lasting some- 
times for days; or even sharp attacks of angina, 
following smoking, and occasionally severe enough 
to prove fatal (vide antea, p. 127). 

This being the state of matters liable to be in- 
duced, even in young and healthy hearts, by the 
abuse of tobacco, it may be readily understood 
that elderly people with feeble hearts ought to be 
very chary even as to its moderate use, and on the 
first appearance of any sign of tobacco poisoning, 
such as cardiac intermission or irregularity, the 
habit ought to be dropped at once if any comfort 
in the future is desired. 

Narcotics in every form damage a weak heart, 

and are too often the cause of its 
Narcotics in ^ , ., . 
any form debility; hence we must enquire into 

injurious to ^]jg habits of every patient, and en- 
deavour to eliminate those which are 


injurious; not always an easy matter, as some 
cling to habit with an intensity which overrides 
even the love of life. Of no habit can this be 
more truly said than of the abuse of opium in 
all its many forms. To attempt to restore the 
dilated heart of an opium-eater who will not for- 
swear his habit is even more hopeless a task than 
to make the same attempt in the case of a beer- 
soaker or an inveterate dram-drinker. I well 
remember telling a gentleman whose dilated heart 
I had for some time been treating in vain that 
I was sure he had not been quite open with me, 
as I could not obtain the expected result from 
the remedies prescribed, and that I was quite 
certain I would not have been disappointed but 
for the existence of some unrevealed obstacle. 
This appeal to his conscience produced the not 
unexpected confession, "Well, to tell you the 
truth, I take a good deal of whisky at night." 
The obstacle once revealed and removed, the hap- 
piest results, I am glad to say, speedily followed. 



All the various symptoms connected with, the 
senile heart may be looked upon as indicating 
cardiac failure, with sequential complications, and 
the treatment must therefore be tonic, with certain 

The drugs useful as cardiac tonics are but few in 
number, but of great value. 

Digitalis is the foremost of all cardiac tonics. 
It gives its name to a whole group of 
J *.9« « *« remedies with similar actions, only one 

princeps of which comes within a measurable 

tonics '"" distance of itself in the possession of 
valuable and reliable properties. An 
indigenous drug of the very highest value, and 
known for more than a hundred years as a most 
reliable remedy in dropsies, its action was so little 
understood, even so recently as twenty years ago, 



that it was called the opium of the heart, and 
looked upon as a most powerful and dangerous 
sedative.^ And even yet the profession are more 
or less hampered in its use by an idea that pos- 
sesses it that digitalis is dangerously cumulative. 
Digitalis, like Fitz-James' blade, is both "sword 
and shield," and he who understands its use will 
never be disappointed by it, the very so-called 
cumulative action being but the necessary result 
of one of its most valuable properties when over- 
done. Given in full doses, at short intervals, dig- 
italis, like many other drugs, is not wholly elimi- 
nated during the interval, but each succeeding 
dose reinforces those that have preceded, till a 
dangerous degree of cardiac contraction may be 
produced.^ For this we should not blame the 
drug, but the prescriber. Even a considerable 
degree of digitalis contraction does not, however, 
seem to be dangerous if wittingly produced and 
carefully watched. It takes a good deal of dig- 
italis to bring a human heart to a standstill 
in systole. Half-ounce doses of the tincture of 
digitalis used to be given safely and repeatedly in 
the treatment of delirium tremens. I, myself, have 
often successfully given drachm doses of the 
tincture every hour, for four or five times, in the 

1 Vide, Edinburgh Medical Journal, February, 1870, p. 743, 

2 Fothergill, On Digitalis, London, 1871, p. 5. 


precritical collapse of pneumonia; and many years 
ago, in treating the dilated heart of a young chlo- 
rotic girl, I kept her pulse for days at 40, and her 
heart-sounds beating with the empty tic-tac of an 
infant's heart (embryocardia). In this case all my 
endeavours failed to contract and cure this dilated 
heart, which always relaxed the moment the dose 
of digitalis was reduced, apparently from sheer want 
of tone in the muscle. Persistent treatment, though 
it failed to contract the heart, yet sufficed to feed 
it. It has kept well fed all these years, and, though 
a loud systolic murmur still indicates the continu- 
ance of dilatation, the patient has long been a 
happy wife, and the mother of several healthy chil- 
dren, with no appearance of any ailment about her. 

What we were, perforce, reduced to in this case 
How to use ^^ ^^ ^^ should ever attempt in the 
digitalis in case of Senile hearts. We need never 
seni e ear s. a^^^^gjjjp^ ^q contract and cure a senile 
dilated heart. It cannot be done, so there is no 
use trying. But we can always improve the 
nutrition of the dilated myocardium, and in doing 
so we gain two ends : we fit the muscle for the 
more perfect discharge of its function, and we en- 
able it better to withstand injurious influences, 
reflex or other. 

With this object in view, we employ only mod- 
erate doses of digitalis, doses which never seem to 


have any cumulative action, or so rarely and 
slightly that we may safely continue them for a 
week or two without observation and without risk. 

These doses are for the British Pharmacopgeia 
preparations : — 

The infusion, half a measured fluid ^°^^fj^ 
ounce. which have no 

The tincture, ten minims. cnmniative 


Each of these doses is equivalent 
to a little more than one grain of the pow- 
dered leaves, so that this may be taken as the 
medium dose that may be safely administered 
every twelve hours, without risk of cumulative 
action. This means that within that space of 
time the quantity of the drug ingested has been 
completely balanced by that excreted, only the 
tonic influence remaining; that is, the improved 
nutrition of the myocardium due to the action of 
the drug while being slowly excreted. I have 
known such doses to be continued for many 
months, sometimes for years. The dose of digi- 
talis is not, however, an absolute one, but is rel- 
ative to the bulk (weight) of the individual, and 
specially to the amount of his blood, a weakly 
ansemic individual tolerating only a very much 
smaller dose than one more plethoric. Now and 
then, too, we come across an idiosyncrasy which 
either tolerates freely a larger dose, or resents any 


but the smallest. Such cases are, however, rare ; 
still, in view of their occasional occurrence, it is 
well that a patient under treatment for the first 
time should be seen now and then for the first 
week or two ; afterwards, when the measure of 
toleration, as we may term it, has been ascer- 
tained, this may be less necessary. 

There is a French preparation of digitalin, pre- 
pared by Nativelle, which is most convenient and 
reliable. It is made up in granules, each contain- 
ing one-quarter of a milligramme (0.003858 of a 
grain) of crystallized digitalin. Nativelle's crystal- 
lized digitalin is said by Brunton to consist chiefly, 
if not entirely, of digitoxin,^ a principle having 
a precisely similar action, but insoluble in water, 
and only sparingly so in alcohol. Be this as it 
may, twenty years' experience enables me to say 
that it is now, and always has been, a thoroughly 
reliable and active drug. One fla§on containing 
sixty granules in two months' time produces quite 
a decided difference in the heart-beat of those to 
whom they have been administered. One granule 
every night at bedtime is a perfectly sufficient 
dose to produce this decided tonic effect on the 
heart, and such a dose may be continued as long 
as may be thought necessary. Now and then a 
larger dose seems indicated, and one granule may 

1 Lauder Brunton's Pharmacology, London, 1891, p. 995. 


be given every twelve hours, but except in bulky 
or plethoric individuals so large a dose as this is 
rarely long tolerated. To give more than two 
granules in the twenty-four hours is almost certain 
to induce speedy intolerance of the drug, and as 
a rule violent sickness. Occasionally even one 
granule in the twenty-four hours is too large a 
dose, and produces uncomfortable sensations. In 
one such case a single granule every forty-eight 
hours proved quite an efficient dose, and as his 
health improved, this patient was afterwards able 
to continue with one granule every twenty-four 
hours for several years. If preferred, Nativelle 
has a syrup of digitalin which contains one-quarter 
of a milligramme in each drachm, and by using it 
the dose may be subdivided as minutely as may be 

The object we have in view when using digitalis 
in a case of senile heart is not to re- rj^^^^^^.^ 
move dropsy, to slow the rate of pulsa- we have in 
tion, or to contract the cardiac cavities, ^j-!,'",.™^ "™^ 
but by the gradual accumulation of a case of 
trifling advantages to tone up and *^™ ^ 
strengthen the cardiac muscle by improving its 
nutrition. Gradually the heart acts with more 
vigour, the circulation improves in steadiness and 
force, any oedema occupying the tissue spaces is 
removed, and thus the blood pressure is lowered 


and a considerable strain taken from the hearfc.^ 
For this purpose only moderate doses are required, 
doses which can be continued for many months 
without any risk of dangerous accumulation, and 
which yet have a decided effect in strengthening 
the heart, improving the tone and elasticity of its 
muscle, and accumulating energy in its ganglia. 
Naturally this process is a slow one, and the benefit 
is not for a time very obvious to the recipient. Some 
years ago a friend called on me and said, " Doctor, 
your medicine is doing me no good." " Of that," 
I said, " you must allow me to be the best judge." 
" But I feel no change in my symptoms, nor any 
action whatever from what you have given me." " I 
expected nothing else; you are too impatient," I 
replied. " Were I to give you medicine in such a 
dose as to produce a sensible action in a few days, 
before long its action would be so unpleasant that 
you would either stop it yourself, or your ordinary 
medical attendant would order you to give it up. 
In a short time the seeming benefit would vanish, 
and you would abuse me for having given you 
medicine which did not agree with you, and which 
gave you no permanent relief. Now, what I have 
given you will not speedily relieve you ; but give 
it time, and it will make you well, and prolong 

1 Vide Hamilton's Pathology, Vol. i., pp. 630 and 694; also 
Edinburgh Medical Journal, September, 1889, p. 213. 


your days in comfort. Two or three months after 
this you will say to your wife some morning, ' Do 
you know, my heart is not so troublesome as it 
was ; I begin to think I am improving ' ; and six 
or eight months after this you will come to me 
and say, 'Doctor, I was preaching last Sunday 
and feel none the worse for it.' " And so it fell 
out ; my friend and his senile heart are nowadays, 
after the lapse of five years, still very good com- 
pany to each other, which for many a day they 
were not. 

The senile heart owes its peculiar symptoms 
and progress to the difficulty which a „..,,. 

^ ° -I Digitalis 

weakened myocardium finds in main- cannot be 
taining the circulation in the face of f^^^^.f "«™ 

° to senile 

the permanent obstacle presented by hearts without 

rigidity of the arterial walls. To seek »^™»««";- 

o ■' ously unlock- 

to excite a heart to more powerful ing the 

action in the face of such an obstacle "'■'^"° ^^■ 

seems fraught with danger ; and we know, indeed, 

that even moderate digitalis stimulation in such 

circumstances is apt to be followed by a worsening 

of the symptoms, sometimes by an increase of the 

cardiac dilatation, always of its erethism. Some 

also object to the use of digitalis when the arteries 

are atheromatous, from a dread of rupturing their 

brittle coats. This last-named danger must be a 

very infinitesimal one, as such an accident is quite 


unknown to me, notwithstanding a continual and 
free use of digitalis. But, indeed, the same means 
of necessity taken to prevent the increase of 
cardiac erethism would also prevent this more 
serious danger. To this end it is needful in all 
such cases to combine the digitalis with some drug 
capable of unlocking the arterioles, and of promot- 
ing the free passage of the blood to the veins. 
These drugs are, iodide of potassium, all the 
nitrites, of which nitrous ether, nitrite of sodium, 
and nitro-glycerine are those most commonly 
used. Digitalis ought never to be prescribed in a 
case of senile heart without the addition of one or 
other of these vascular stimulants, and of these 
iodide of potassium is the most generally useful, 
acting well and persistently in a moderate dose, 
and free from any objectionable effect. 

If, at the commencement of treatment, the heart 
has been much neglected, the dilatation consid- 
erable, and the irregularity great, it is very desira- 
ble to begin with larger doses of digitalis than 
those just recommended, so as to gain control over 

^ the rate and rhythm of the heart as 
Large doses of _ ^ 

digitalis some- rapidly as possible ; but these large 
times requi- (jgggg ^pg jjo^ likely to be required for 

site, even m j i 

case of senile any length of time, and ought to be 

^"''^' pretermitted for at least a couple of 

days before the patient is put upon the smaller 


doses for a continuance. Where there is oedema 
of the lower limbs, a perfectly dry diet with tonic 
doses of digitalis are often quite sufficient to re- 
move the fluid, and that in a very short time. 
But if the dropsy is at all considerable, it must be 
treated as an ordinary case of cardiac dropsy, and 
in such cases it is a great saving of time to drain 
the limbs. In all senile hearts, whatever their 
character or special symptom may be, we must 
always remember that digitalis uncombined with 
one or other of the vascular stimulants is never so 
beneficial as when it is so combined, is certain, 
indeed, to produce discomfort, and is very likely 
to do serious damage. 

The only other member of the digitalis group 
which has any pretensions to rival 
digitalis itself, is strophanthus and its ^Zpianthus. 
active principle strophanthin. Stro- 
phanthus is, however, so much more uncertain in 
its action, especially as to its feeding or tonic 
properties, than the leading member of its group, 
that I have never felt inclined to displace our own 
pre-eminent and indigenous drug in its favour. 
Strophanthin possesses, however, two advantages 
over digitalin : it is readily soluble in water, and 
it seem to act with great rapidity. There are, 
therefore, conditions in which strophanthin is to 
be preferred; but these are unusual and excep- 


tional at all times, and are rarely found in connec- 
tion with the senile heart. 

Nux vomica is an excellent tonic for the senile 
heart and its concomitants, but as its usefulness 
depends upon its active principle, it is more advan- 
tageous and contributes to greater accuracy of 
dosage to employ the liquor strychnince hydro- 
chloratis rather than any of the cruder prepara- 
tions. The maximum benefit is only to be got 
from any drug by using the maximum dose for a 
sufficient length of time ; and to do this safely with 
any remedy, but especially with so powerful a 
drug as strychnine, it is needful to be both accu- 
rate in the dosage and regular in the times of 
administration. Strychnine is eumu- 
admirable lativc in its action, but by strict adher- 
tonicfor the eucc to the rulcs laid down, it may be 

senile heart. 

used contmuously and safely for many 

years. I have known five minims of the liquor 

strychnince (^^ of a grain of strychnine) to be 

taken twice a day for over ten years with the very 

best results ; at the end of that time symptoms of 

saturation began to appear, and the strychnine 

had to be discontinued. But it was no longer 

required ; the puny, delicate, middle-aged woman 

is now both strong and healthy. It is only rarely 

that a larger dose than five minims of the liquor 

strychnince can be given daily with benefit ; three 


such doses, fifteen minims instead of ten in the 
day, are generally followed by symptoms of poison- 
ing in no long time. Idiosyncrasy occasionally 
turns up, and for this we must be prepared, but 
the dose indicated is the maximum dose adminis- 
trable to by far the larger number of mankind, 
for any length of time at least. In ansemic 
patients there is often an intolerance of strych- 
nine, and if employed at all, it has to be given in 
almost infinitesimal doses. Strychnine acts in two 
ways : it is an admirable tonic for the stomach, 
especially in those catarrhal conditions accompa- 
nied with venous congestion, so commonly pres- 
ent when the circulation is feeble. In this way 
the digestion is improved and the blood enriched, 
so that the body generally, and the heart in par- 
ticular, gets better nourished. Strychnine has 
also a specially stimulating effect on the nervous 
system generally ; consequently it stimulates and 
renders more excitable the vaso-motor centre, and 
the cardiac ganglia, probably even energizing that 
primordial power of spontaneous movement pos- 
sessed by the cardiac muscular fibre itself — a 
power which may be looked upon as a remnant 
of the vis insita, the once diffuse nervous force. 
In virtue of this action on the heart and nerve 
centres strychniiie increases the cardiac force, 
raises the intraarterial blood pressure, and is — 


next to digitalis — the most excellent tonic we 
possess for all feeble and dilated hearts. In the 
less serious class of cases it is sufficient of itself 
to give tone both to the heart and the system 
generally, while in the most serious cases it is a 
most useful adjunct to digitalis. 

Arsenic is another of our most valuable tonics. 
It is advantageously employed in many forms of 
disease, and it is quite indispensable 
„J'o!lx! in the treatment of the senile heart. 

It is very useful in those congestive 
conditions of stomach which accompany cardiac 
failure ; and its effect in angina is sometimes 
almost magical, the suffering disappearing like 
a dream, quite apart from any influence exerted 
on the cardiac failure upon which that suffering 
seemed to depend. Masselot and Trousseau have 
both remarked upon the increased capacity for 
exercise that follows the administration of arsenic,^ 
and this doubtless depends upon the same general 
tonic influence, affecting the lungs, heart, and 
blood, that makes breathlessness a thing unknown 
to the Styrian mountaineer, and restores the 
blooming coat and friskiness of youth to old 

1 " J'insiste sur ce phenomene eprouve egalement par M. 
Masselot, et signal^ pai- lui en ces termes : ' tres grande apti- 
tude a, la marche.' " — Traite de Therapeutique, par A. Trous- 
seau et H. Pidoux, Vol. i., p. 312. 


and seemingly worn-out horses. The Styrians 
are accustomed to take large doses, as much 
sometimes as five grains, of pure arsenious acid^ 
in the day, but such dangerous doses are by no 
means necessary to obtain the tonic benefits of the 
drug. Most excellent results indeed occasionally 
follow the prolonged use of almost infinitesimal 
doses. I well remember one old gentleman, 
exceedingly sensitive to the action of drugs, to 
whom the -^ of a grain of arsenious acid was 
quite poisonous, but who could tolerate the ^^-^ 
of a grain without difficulty. After taking this 
minute dose daily for two or three weeks, and 
nothing else, for a dilated and hypertrophied 
heart beginning to fail, he said to me, " I don't 
know what benefit you expected from the treat- 
ment, but I know what I have received; I can 
go upstairs much easier than I used to do." 
Arsenic may be given alone, and in anaemic and 
very sensitive patients who can only tolerate a 
very minute dose this is often the best way of 
employing it. To these one granule of arsenious 
acid containing -^^ or ^\^ of a grain may be 
given after food once or twice a day for many 
months vrith only increasing benefit. More usually 

' Dr. E. Craig Maolagan, " On the Arsenic- eaters of 
Styria," Edinburgh Medical Journal, September, 1864, pp. 
203, 206. 


it is better to combine tbe arsenic with digitalis 
or strychnine, or witb both. In making any of 
these combinations, the liquor arsenici hydrochlo- 
rici is the better preparation to employ, and in 
combination, with the liquor stryehnince hydro- 
chloratis it is the only one that ought to be used, 
as with it the other preparations, the liquor arseni- 
calis, or the liquor sodii arseniatis, make an incom- 
patible and more or less unsightly mixture. As 
we learn from the histories of the Styrian arsenic- 
eaters, arsenic is a poison to which the system 
may be gradually habituated, so that even large 
doses may be taken for many years, not only with 
impunity, but with positive benefit. When given 
therefore in the moderate medicinal dose of two 
or three minims of one or other of the fluid prepa- 
rations, we may safely continue them twice a day 
for as long as we think needful, without any mis- 
givings. Nor need we have any dread of any 
danger in leaving off the drug after long con- 
tinuance, as was at one time alleged. A little 
caution may be required in commencing its use, 
as idiosyncrasy plays a marked part in relation to 
arsenic, but it is only rarely that we fall in with 
those who are extra-sensitive to its action. 

When the blood is deficient in haemoglobin, iron 
is a necessity. It is best given along with food, 
and should never be combined with digitalis, as 


such a combination is very apt to sicken. The 
proto-salts of iron are to be preferred 

Iron useful 

to the per-saits, as they are more whenhsmo- 
easily decomposed by the acids of the g^o^in ^^fi- 
gastric juice, and are thus more read- 
ily assimilated. As a rule, large doses are not 
required in cases of feeble or dilated heart. 

Intra-arterial blood pressure depends upon the 
distension of the arterial system bv „„ ,, , 

•' •' What blood 

the blood contained within it. This pressure 

vascular turgescence, in its turn, de- '"'*"""2'^«- 
pends upon the relation between the amount of 
blood pumped into the arteries by the heart and 
the outflow through the arterioles. After middle 
life the outflow through the arterioles is hindered 
by obsolescence of the capillaries and by loss of arte- 
rial elasticity, and the blood pressure 
is raised by these obstacles, even with ^ '''^^ ^''"'.'*. 

•' ' pressure ongi- 

a heart beating at its normal rate and nates trouble 

force. A healthy heart has sufficient ^°*j/'"''' 
reserve force to enable it to cope suc- 
cessfully with the demand for extra exertion thus 
made upon its powers, and it thrives upon its ex- 
ertion. But when the heart is from any cause 
feeble or ill-fed, it fails to respond, and it suffers, 
its suffering giving rise to those varied symptoms 
comprised under the term " senile heart " (vide 
antea, pp. 27, 35, etc.). 


As these sufferings are caused and maintained 

by the high blood pressure, whatever 

lowers the lowers this always gives relief. Hence 

blood pressure these Sufferings are capable of being 

gives relief. ,. i , • j c . . 

relieved by various modes oi treat- 
ment which are not all of them truly remedial. 
Permanently to remove these sufferings, we must 
not content ourselves with merely reducing the 
blood pressure ; we must also so strengthen the 
heart as to enable it to cope with a blood pressure 
always over the normal of adolescence, and which 
is liable to be suddenly abnormally raised by many 
causes. Cardiac tonics are, therefore, required. 
But all cardiac tonics — except, perhaps, arsenic 
— are also cardiac stimulants : they increase the 
elasticity and contractility of the heart, and, in 
certain conditions, they improve the heart's metab- 
olism by enabling it to feed itself with a larger 
blood-wave at a higher pressure. When the heart 
is feeble, however, this is just what cannot be 
done. The whole trouble has arisen because the 
blood pressure is already too great for the powers 
of the heart, and if we goad this feeble organ to 
further exertion, for which it is unfit, we either 
increase any dilatation that may be present, or 
induce erithistic tachycardia or irregularity. Car- 
diac tonics don't agree ; but we can make them 
agree by combining a vascular stimulant with a 


cardiac stimulant; then things work smoothly. 
The heart, no lonarer opposed by an , 

_ ° '^^ •> Importance of 

obstacle it can either not overcome, or the eombma- 
only imperfectly and with suffering, f™ »/"««»«- 

•z ^ •' o' lar stimulants 

now contracts more perfectly, feeds with cardiac 
itself better, and all its sufferings f™«'«f^™ 

' ° the treatment 

vanish. of the senile 

Vascular stimulants are agents ^"'^*' 
which dilate the peripheral vessels (arterioles) 
and so promote the flow of blood from the arteries 
into the veins and lower the intra-arterial blood 
pressure. Iodide of potassium is not, perhaps, 
generally regarded as a vascular stimulant, but in 
so far as it promotes the flow through the arteri- 
oles, and lowers the blood pressure, it is an emi- 
nent member of that group, as has been established 
experimentally, and duly recognized in relation to 
the treatment of aneurism.^ It is not rapid in its 
action, but it is persistent, two or three grains 
every twelve hours being quite sufficient to enable 
digitalis to be given freely without any cardiac dis- 

All the nitrites are vascular stimulants. Spirit 
of nitrous ether or nitrite of sodium may be so 

1 Vide Bogolepoff, Zur Frage der Physiologisclien Wirkung 
des lodkalium, Moskauer Pharmacolog. Arbeiten, S. 125 ; and 
Virchow's Jahresbericht, 1876, erster Band, S. 402 ; also Bal- 
four, op. cit., second edition, p. 459. 


employed, but their action does not last so long as 
that of the iodide of potassium ; while in rapidity 
they are far inferior to either the nitrite of amyl 
or nitro-glycerine. Besides being a vascular 
stimulant, with all the actions belonging to such 
remedies, nitrite of amyl is also an analgesic. A 
former patient who suffered from intense anginous 
pain, accompanying a large aortic aneurism from 
which he died, always found the analgesic action 
absent unless the drug was freshly prepared. 
When not quite fresh, his face flushed, and all the 
usual symptoms due to amyl were produced, but 
the pain was not relieved. Since then the amyl 
has been retailed in hermetically sealed glass cap- 
sules, apparently with the effect of retaining the 
analgesic properties. The flushing of the face, 
the fulness of the head, and the rapid action of the 
heart produced bj^ the amyl are very disagreeable to 
some patients ; they do not seem to be in any way 
injurious. I have known amyl to be used with 
great freedom in angina. One medical friend, who 
suffered much from angina, connected with aortic 
regurgitation, not content with inhaling it fre- 
quently during the day, used to soak his pocket 
handkerchief in the amyl and go to sleep with it 
lying on his face, without any ill results. The 
action of the amyl is very evanescent, the smell 
is disagreeable, and the quantity in a single 


capsule is rather small, but that is a matter easily 

Nitro-glycerine, glonoin, or trinitrin, is said to 
be a nitrate of glyceril, but its action is that of a 
nitrite. In ordinary medicinal doses of -^-^ to -j^ 
of a grain it rapidly lowers the blood pressure and 
relieves the pain of angina. The action of nitro- 
glycerine is somewhat prolonged, from one to 
three or four hours, according to the dose. By 
giving an anginous patient three or four doses of 
nitro-glycerine in the day he can often be kept 
quite free from his attacks ; it is well to give him 
a dose half an hour before any exertion likely to 
bring on an attack, and also just before going to 
bed. As a one per cent solution it acts very 
rapidly, and the dose is from one-half up to ten or 
more minims. In the form of tabellse, made with 
chocolate, each containing the j^ of a grain, it 
acts nearly as quickly, — in about half a minute, — 
if the lozenge be chewed as rapidly and perfectly 
as possible. The drawbacks to the use of nitro- 
glycerine are its liability to produce headache, 
giddiness, throbbing of the cerebral arteries, and 
palpitation of the heart, but it is remarkable how 
seldom these are complained of. In the form of 
tabellse, — tablets or lozenges, — the nitro-glycerine 
is easily carried about, a,nd is readily available on 
the slightest indication of pain. 


Throughout the literature of cardiac disease 

there are recorded many cases of ex- 

Colchicum treme and distressing irregularity of 

service in the heart at once relieved by a fit of 

irregularity ^^^ ^^ ^f ^^^^^ ^^^^^ ^^ ^0^^^. 

0/ the heart. " 

have been cured just as well and as 

speedily by the use of colchicum. This is a 
matter not to be lost sight of. The senile heart is 
the gouty heart, and anti-arthritic medication is 
always useful, sometimes of paramount impor- 
tance, and it may always be combined with other 
necessary remedies, notably with digitalis. 

In all cases of gouty heart it is of consequence 
to keep the primce vice free from acidity, and this 
of itself is often a cure for many of the cardiac 
symptoms, especially irregularities of rate and 
rhythm. I have known many who have taken 
Avith great benefit a teaspoonful of carbonate of 
soda, or of the bicarbonate of potash, at bedtime 
every night for many years. This medication has 
seemed to me to favour the formation of Heber- 
den's knobs, but it has undoubtedly been attended 
with relief to the cardiac symptoms. 

A thorough alkalizing of the primce vice is also 

r . . readily carried out by the use of Vichy 
Importance of ■' •' •> 

alkalizing the water, either plain or aerated. This 
pnmjB vise. ^^^ either be taken as ordinary drink, 
or a small tumblerful may be taken before break- 


fast, while dressing, and another about an hour 
before dinner. A third tumblerful, on going to 
bed, is an excellent thing for those who are gouty 
and have no marked cardiac symptoms ; but it is 
not wise for a heart patient to go to bed with a 
full stomach, though its contents be only water. 
The thorough alkalizing of the primcB vice is an 
excellent adjuvant, and often of itself suffices to 
remove slight irregularity of the heart. 

Dr. Gregory's gouty powder, or its modern 
analogue rhubarb, with the bicarbonate of potash 
or soda, is a most excellent antacid aperient, as I 
suppose every gouty person knows full well. 
When there are symptoms of gastric irritation, the 
addition of bismuth to this powder is of great 
advantage, and has often been successfully em- 
ployed in cardiac intermittence or irregularity 
when accompanied by such symptoms. 

An active cholagogue purge is one of the most 
efficient means of lowering the blood „ , ^ 
pressure and relieving the heart. This cathartics 
it does in virtue of the large quantity '^^*,^-^".,*P 
of fluid it drains from the blood, as the blood 
well as by the increased amount of ^'"^**"''^- 
blood attracted to the intestinal mucous membrane 
by the irritation of the purgative. Any cathartic 
would suffice for this, but a cholagogue, or one 
which acts by increasing the secretion of the liver, 


has the additional advantage of directly relieving 
the right side of the heart.^ 

Flatulence is a symptom that often produces a 
great deal of distress, not from mere distension, — 
though that, too, occasionally disturbs, — but by its 
action on the heart, causing intermission, irregu- 
larity, or severe attacks of tremor cordis. In a 
stomach congested and catarrhal from feeble cir- 
culation, an amount of flatulence insufficient to 

produce any feeling of distension often 

Flatulence, . . 

its results, gives rise to great cardiac uneasiness 
audits an(j disturbance that passes off at 

once on eructation. These symptoms 
are generally of reflex origin, but in long, narrow 
chests flatulent distension often seems to produce 
cardiac disturbance by direct pressure. At least, 
it is not uncommon for such a patient — to all 
appearance, and to his own feeling, in perfect 
health — on stooping to pick up a pencil, or tie his 
shoe, to have his heart run off in a fit of irregu 
larity or of tremor. So sudden and unexpected a 
seizure is very alarming to most. It is the one 
occasion upon which a sip of spirits — whisky or 
brandy — seems permissible. At the same time 
half a drachm of spiritus ammonice aromaticus, 
with an equal quantity of spiritus lavandulce com- 

1 Lauder Brunton, Disorders of Digestion, Macmillan & Co., 
London, 1886, p. 208. 


positus, in a little water will give relief as certainly 
and as quickly, but it is not so easily carried about 
as a small flask of spirits ; moreover, the spirit acts 
best undiluted, which is handy. The treatment of 
flatulence demands careful dieting, apart from the 
special needs of the case generally, along with the 
persistent use of the old-fashioned cobbler's pill, 
the compound galbanum pill of the last Edinburgh 
Pharmacopeia, the pilula assafoetidce composita of 
the British Pharmacopeia. 

Narcotics are of use in the treatment of affec- 
tions of the "senile heart to relieve pain 
and to procure sleep. In relieving and their 

pain we generally also induce sleep, "*^ *" 

. relieve pain. 

but there are many hypnotics well 

fitted to induce sleep which are of little use to 
relieve pain. There is only one hypnotic which is 
also a sure analgesic, and that is opium. Its alka- 
loid, morphia, acts so rapidly and certainly, and is 
so readily administered hypodermically, that it 
deserves every confidence. Morphia is a useful 
and reliable remedy, not only in pain- 
ful angina, but also in those vaso- ^^1^1°^ 
motor anginas which are attended by 
great breathlessness without pain, inasmuch as it 
is not merely an analgesic, but also an anti- 
spasmodic, and it lowers the blood pressure by 
relaxing the arterioles and so favouring the trans- 


ference of the blood from the arteries to the veins. 
Morphia is not only an analgesic and anti-spas- 
modic, but also a hypnotic of great power, and as 
it has no ill effect, either on the heart or respira- 
tory centre, it may, when required, be freely used 
for both purposes. The drawbacks to its use are 
the headache and gastric disturbance it is liable to 
produce, and also the risk of inducing the morphia 
habit. There is nothing, however, that can re- 
place it in certain cases, and in them there seems 
but little risk of provoking the habit. 

Chloroform is sometimes useful to relieve pain, 

when severe, till morphia has had time 

ctionof ^p ^^^^ Chloroform is analgesic and 

chloroform. o 

hypnotic only because it is anaesthetic. 
It relieves pain and induces sleep only by produc- 
ing entire loss of sensibility to all external impres- 
sions, — a condition not wholly devoid of danger, 
and requiring to be carefully watched, as the 
border line of safety is so easily crossed. With 
careful dosage there is no risk whatever in giving 
it to diseased, feeble, possibly, or actually, fatty 
hearts.! The risk is not in the drug itself, but in 
its administration. 

Chloral, like chloroform, is an anses- 
tmrli"^ thetic, and in virtue of this property 

it both relieves pain and induces sleep. 
^ Vide Balfour, pp. cit., second edition, 1882, p. 308. 


It does not, however, act so rapidly as either 
morphia or chloroform, and is not, therefore, likely 
to take the place of either. Properly adminis- 
tered, it is a perfectly safe and certain soporific, 
and as such it has its use in certain cases. Lie- 
breich's chloral is the only preparation always 
safe, and, therefore, always to be used. Fifty 
grains of this will put all well people to sleeps 
forty grains will put to sleep a great many who 
are not well. It is given off at the rate of ten 
grains an hour, so that after the lapse of forty 
minutes the organism still retains over thirty 
grains. To this, if need be, we add a second dose 
of forty grains. This vsdll put to sleep a very 
large proportion of those still sleepless ; and I 
have never known any one resist a third dose of 
forty grains, nor, I may add, have I ever seen any- 
thing but the best results from even the full dose 
of 120 grains. This dose, though a large one, is 
quite within the limits of safety, even if swallowed 
all at once. But, given in the manner prescribed, 
there is in the organism at the end of 120 minutes 
little over 100 grains. Given in this way, chloral 
is a perfectly safe and perfectly certain hypnotic, 
and there are cases even of heart trouble in which 
this knowledge may be useful.^ Both chloral and 

1 Kichardsoii says that a man weighing 120 to 140 pounds is 
tlirown into a deep sleep by ninety grains of chloral, and that 


chloroform lower the blood pressure by causing 

dilatation of the arterioles, probably by paralyzing 

the vaso-motor centre. 

There are three hypnotics, pure and simple, 

which deserve attention in those many cases of 

insomnia which so often accompanies a gouty and 

feeble heart. The first of these is 

Action of paraldehyde, a very reliable hypnotic 
paraldehyde. ^ ^ ^ j . 

without any analgesic properties. 

Under its use the blood pressure falls from paral- 
ysis of the vaso-motor centre, but the heart seems 
to be unaffected. Paraldehyde may be given in 
considerable doses, as much as a drachm every 
hour, till sleep ensues. The great drawbacks to 
its use are, its vile taste, which may be overcome 
by giving it in an aromatic mixture or in a cap- 
sule, and the disagreeable odour which the patient 
exhales for the twenty-four hours following its 
ingestion, which nothing seems able to remedy. 
The second hypnotic deserving of attention is 
cMoralamid. This is an excellent 
tu^lamid. soporific: it lowers the blood pres- 
sure, but it also quickens the heart- 
beat, and is thus inferior in usefulness to the 
third hypnotic to be spoken of immediately. 
In spite of this drawback, chloralamid may be 

the sleep which follows 140 grains Is dangerous. — Journal of 
Mental Science, Vol. xviii., p. 118. 


given quite safely to cardiac patients for many 

weeks. It is not cumulative in its action, nor 

does use ever seem to necessitate an increase of 

the dose. Forty grains is an efficient dose. This 

should be rubbed up with spirit (0.920 sp. gr.) 

donee solutio fiat, and taken with the addition of 

a little syrup. 

The third hypnotic of importance is chloralose, 

a drug of quite recent introduction, 

but which promises to be a most val- ^°**"" °-^ 
■^ chloralose. 

uable addition to our armamentarium. 
Chloralose lowers the blood pressure ; but, even 
in large doses, it has no exciting effect on the 
heart, seeming rather to steady and regulate the 
action of that organ. Patients fall asleep quickly 
under its use, and they waken easily and refreshed. 
There is no headache and no gastric disturbance, 
the appetite seeming to be rather improved. Even 
when taken in an excessive dose, the heart is never 
affected injuriously, the only result of an over- 
dose being a certain amount of intoxication. The 
only drawback to the use of chloralose is a ten- 
dency to act irregularly, and to induce nervous 
symptoms in hysterical and neuropathic patients. 
The dose of chloralose is from two to eight grains, 
and it is best administered in a cachet. A very good 
way of giving chloralose is to give a cachet con- 
taining three or four grains at bedtime. Should 


the patient have a good night, well and good; 
but should he wake after an hour or two of sleep, 
the repetition of a similar dose will secure a good 
night's rest. 

The bromides are often of the greatest service, 
especially in the senile hearts of fe- 

Useofthe t^ J . t, 

bromides as males about their climacteric. But 

the bromides are pure sedatives, and 
are not to be trusted to for any hypnotic action. 
The bromide of potassium is supposed to enfeeble 
the heart's action ; a similar objection is not appli- 
cable either to the bromide of ammonium or of 



There is, strictly speaking, only one possible 
prognostic dictum applicable to all senile hearts ; 
fortunately a lapse of many years often intervenes 
between such a prediction and its fulfilment. 

When prognostication is required in reference 
to any special symptom, and its relation to the 
prolongation of life, the answer is neither so 
simple nor so certain. 

Precordial anxiety often distresses a patient 
greatly. It is the earliest symptom prognosis in 

of the senile heart (antea, p. 35), relation to 

and the prognosis is favourable pro- precordial 

vided the cause is remediable. anxiety. 

If the cause of myocardiac weakness is irre- 
mediable, or if a remediable cause is j„j,,„,.,,^„„ 
neglected, and allowed to continue and 
its evil influence, the weakened myo- '^"'"^'^ '*" ^' 



cardium speedily comes under the influence of 
reflex inhibition, and the heart's action becomes 
intermittent or irregular. Now, a man with an 
intermittent or irregular heart may live for many 
years ; but his life is handicapped by his heart, and 
if the cause of the myocardiac debility is irre- 
mediable, or is carelessly allowed to continue its 
injurious influence, in no long time the heart 
dilates (antea, p. 40), and the declension be- 
comes more rapid. At any age an intermittent or 
irregular heart is amenable to treatment, and may 
be cured. But a heart dilated after middle life is, 
to say the least of it, only rarely rehabilitated ; it 
has taken a downward step which is seldom re- 
traced. Life is now more seriously handicapped ; 
breathlessness and oedema are not long in follow- 

Any violent shock may force even a strong 
heart to intermit or become irregular. But in 
such a heart intermissions die away in from six 
months to a year (antea, p. 43). Any sudden 
shock acting on a feeble heart may prove imme- 
diately fatal, or a less severe shock, worry, or 
anxiety may bring on intermission and irregularity, 
or may precipitate serious dilatation of the heart, 
terminating fatally in a few months, anticipating 
by more than a dozen of years the natural progress 
of the affection (antea, p. 44). 


Palpitation affects the young rather than the 

old, and though a distressing symptom, 

it is rarely attended by any danger 

(antea, p. 63). 

Tremor cordis is a most alarming symptom to 

the sufferer. It does occur in early 

adolescence, but rarely; after middle ^'■«"<"" 

•' cordis. 

life it is common enough. It does not 
seem to have any marked injurious influence, and 
though, perhaps, not specially fayourable to lon- 
gevity, any effect it may have in shortening life, or 
even in promoting cardiac dilatation, has not as 
yet been ascertained. Tremor cordis seems to be 
always connected with gastric disturbance, and is 
rarely unaccompanied by some of the other phe- 
nomena of the senile heart (antea, p. 64). 

Tachycardia is always a symptom (antea, p. 

71), and its prognosis depends upon 

^ , T- 1 1 Tachycardia. 

its cause. When tach3'-cardia has been 

brought on by vagus poisoning, as by alcohol, 
tobacco, etc., the prognosis is not serious, though 
there is considerable temporary risk to an aged 
heart. Reflex tachycardia (antea, p. 82) is in 
most cases readily curable, though it sometimes 
lasts for years, apparently without any detriment 
to the sufferer. When associated with inflamma- 
tory affections of the myo- or endocardium, the 
prognosis must be very guarded. It becomes less 


serious when the affection gets localized as a val- 
vulitis. The prognosis of tachycardia is most 
serious when it is associated with compression of 
vagus by a tumour. 

Bradycardia. Of this there are two forms : one, 

the gouty variety, depends upon alter- 
Bradijcardia. . , . , , ^n^ 

natmg hemi-systoles (^antea, p. yZ); 

and the other, the true bradycardia Qantea, p. 106). 
Both varieties are associated with dilatation of the 
heart, but the hemi-systolic form is amenable to 
treatment, and its prognosis is that of an ordinary 
dilated heart, dependent on the age of the patient 
and the condition of his myocardium. True brady- 
cardia — and the two varieties can always be differ- 
entiated by their sphygmograms — is a very serious 
affection, and life seems rarely to be prolonged 
beyond three or four years, the end being pre- 
cipitated by an epileptic attack. Hemi-systolic 
bradycardiacs are also exposed to a similar risk, 
but in them this risk is never so imminent, and it 
may be averted. 

Delirium cordis is always a serious affection. If 

it be impressed on a strong heart by 

Delirium ^ combination of work and worry, it 

cordis. _ _ ■'_ 

may, with care, continue to handicap 
the sufferer for as long as twenty years. As a 
rule it is most likely to be found in connection 
with feeble, dilated hearts, and then a fourth part 


of that period will probably cover the termina- 

Angina pectoris affords an instance in which 
experience enables us to give a more 

hopeful prognosis than professional ^"S'*"'' 

opinion would at first be inclined to 

homologate. Every case of so-called pseudo- 
angina must be considered on its own merits. 
Hysterical angina is of little importance. In 
gouty angina, if the attacks are hysterical in 
character, it must come under that category ; if 
otherwise, it must be considered as an ordinary 
angina. In every case of angina tlie greater the 
suffering of the patient, and the less there is dis- 
coverable wrong with the heart, the greater the 
danger, and at the most a few months will include 
the termination of the case. If the heart be simply 
dilated, treatment may be of much service, and life 
may be prolonged for a dozen of years. If the 
heart is already considerably hypertrophied before 
the angina sets in, treatment is never of so much 
service, and life is not likely to be so prolonged. 

Affections of the heart, and especially senile 
affections of the heart, are not adapted for accu- 
rate prognosis. In all of them the element of 
uncertainty bulks too largely : we must therefore 
carefully refrain from any too dogmatic assertion. 
Still, it is of consequence to know the exact 


nature and the probable result of any special 
S3rmptom, such as tremor cordis; and though 
somewhat wanting in definiteness, the foregoing 
statements may yet be useful to many. 

Tabular Recapitulation of Treatment. 

In every case careful removal of the Icedentia. 
Precordial Careful dieting ; cardiac tonics ; rest 

anxiety. ^t first, afterwards regulated exercise. 

Careful dieting; vascular stimulants, combined 
with cardiac tonics ; sedatives, espe- 
andirregu- cially for women about their climac- 
"'^'^' teric, occasionally hypnotics ; antacids 

and anti-arthritics ; assafcetida (j)il. galbani co.') ; 
moderate exercise. 

Antacids ; stimulants ; mustard over precordial 

region; hot foot-baths. In interval 

strengthen patient by open-air exer- 
cise, good food, and such tonics as may seem 
needful, especially iron. 

Tremor Careful dieting most important ; ant- 

cordis. acids ; anti-arthritics ; pil. galbani co. 

Careful dieting; in recent cases following car- 
diac overstrain, belladonna, or atropine, 
must be pushed till pupils dilate. In 
cases of poisoning by tobacco or alcohol, tonic 
doses of digitalis useful. Cardiac tonics, espe- 
cially digitalis and arsenic, continued for a long 


time in moderate doses, supplemented by hyp- 
notics at bedtime, especially morphia. Digitalis 
most useful in vagus paralysis, morphia in affec- 
tions of the sympathetic. Chelate of soda slows 
the pulse, but it destroys the blood corpuscles, 
and the benefit is thus a doubtful one. Antipy- 
rine has been recommended theoretically. Faradi- 
zation of the skin over the precordia, or of the 
vagus nerve ; or the skin or vagus may be gal- 
vanized. Compression of the vagus. Forced 
inspiration, holding the breath as long as possible. 
Ether sprayed along the cervical spine. A chlo- 
roform poultice over the precordial region. 

In the hemi-systolic variety, cardiac tonics, espe- 
cially digitalis. In true bradycardia 

,..,.. . T • Bradycardia. 

digitalis IS also indispensable, to main- 
tain the elastic tonicity of the heart, and to en- 
able the heart to cope with the exceptionally high 
blood pressure (anUa, p. 106) prevalent during 
part of the systole. 

Careful dieting, vascular stimulants, Dairium 
cardiac tonics, antacids, and anti- <iordis. 

During the paroxysm, nitro-glycerine, nitrite of 
amyl, chloroform and morphia. Dur- 
ing the interval most careful and ^^^^^l^^ 
abstemious diet, especially towards 
evening. Vascular stimulants in combination with 


cardiac tonics, especially arsenic. Exercise is to 
be avoided, and only undertaken when duly pre- 
pared for by the ingestion of some vascular stim- 

Such, then, is the armamentarium most useful 
in senile heart troubles. Its constituents are all 
valuable remedies, and though some of them are 
interchangeable, yet each has its own peculiar 
mission for which it is best adapted. Each case 
must be carefully considered from every point of 
view, thoroughly individualized, and the treat- 
ment best adapted to attain the end in view firmly 
laid down and persistently carried out. A disease 
that has been gradually coming on for thirty or 
forty years cannot be expected to yield to a week 
or two of treatment, however skilfully devised or 
carefully carried out. It often takes many months 
of care before an irregular heart is made regular, 
or the declension of a failing heart is arrested. In 
time, however, all this can be done. Time, how- 
ever, is required ; for it is not to be done by any 
dexterous legerdemain, but by the skilful imita- 
tion of natural processes, and by the steady accu- 
mulation of trifling advantages ; and our drugs 
must be mixed like Opie's colours — with brains. 


Aconite, action of, 81. 
Action, idio-ventricular, 39. 
irregular, of heart, how pro- 
duced, 40, 48. 
irregular, of heart, danger of, 
Adipositas cordis, 251. 
Age, the result of tissue change, 
not of years, 19. 
alteration In arterial system 

due to, 13. 
typical death from, 18. 
Alcohol unsafe for aged hearts, 

Amyl, nitrite of, 276. 

nitrite of, an analgesic, 
Anaholic nerve of heart, 39. 
Ansemia, a source of heart 

trouble, 29. 
Anaesthetics, 282. 
Analgesic, the only real, 281. 
Angina pectoris, 115. 

may occur in early life, 116. 
syndrome of, 121. 
prognosis in, 141, 291. 
cause of, 125. 
Angina, vaso-motoria, 131. 
Antacids, 278. 
Anti-arthritics, 278. 
, Anxiety, precordial, 35. 
Aortic second, accentuation of, 
accentuation of, what it indi- 
cates, 57. 

Aortic second, a booming, 57. 
regurgitation, how produced, 

systolic murmur, 58. 
systolic murmur precedes re- 
gurgitation, 58. 
Arrest of heart's action, volun- 
tary, 67. 
Arsenic as a cardiac tonic, 270. 
use of, by Styrians, 270. 
use of, may be continued for 
years, 272. 
Arterial system first to fail, 19. 
Arteries of the yoimg may be 

rigid, 229. 
Arterio-capillary fibrosis, 200. 
Arthritis, rheumatoid, 181. 
Asthenia, ingravescent, 29. 
Atherosis, 205. 
Asthma, cardiac, 135. 

death from, 137. 
Asystole may be sudden or in- 
gravescent, 80. 
case of ingravescent, 139. 
Angmentor and accelerator 

nerves, 37. 
Auricular murmur, its position 
and cause, 55. 
why not always to be heard, 
Auscultation a means of detect- 
ing cardiac dilatation, 53. 

Balfour, "W., his treatment of 
gout by massage, 172. 




Bile, the mere drainage of a 
manufactory, 187. 

amount of, in man, 188. 

free secretion of, relieves the 
heart, 189. 
Bismuth, 279. 
Blood pressure, what it is, 273. 

in youth, 11. 

rises when growth ends, 12. 

changes in, from age, 14. 

an increase of, embarrasses 
the heart's action, 273. 

increased, tends to dilate the 
heart, 60. 

a healthy heart successfully 
copes with, 25. 

lowering the, relieves a weak 
heart, 274. 

effects of high, intra-pulmo- 
nary, 159. 

effects of low, intra-pulmo- 
nary, 160. 

effects of vascular environ- 
ment on, 27. 

lowered by vascular stimu- 
lants, 275. 

lowered by cholagogue ca^ 
thartics, 279. 

indications, diagnostic from 
high, 226. 

indications, diagnostic from 
low, 225. 

effects of, on arterial ten- 
sion, 228. 
Bradycardia, 51, 93. 

hemi-systolic, 92. 

hemi-systolic, case of, 92. 

prognosis of, 290. 

true, 107. 

Holberton's case of, 99. 

case of, 109. 

Bromides as sedatives, 286. 
Bulimia, gouty, 186. 

Capillaries, phenomena due to 
obsolescence of, 14. 

Cardiac movements primordial 
in character, 36. 

influence of nervous system 
on, 37. 

irritability, 220. 
Case of dilatation of heart, 42. 

gouty glycosuria, 191. 

supposed fatty heart, 216. 

Colonel Townsend, 67. 

illustrative of angina, 145. 

angina in young woman, 122. 

ingravescent asystole, 139. 

irregular heart, 46. 

tachycardia, 78. 

bradycardia, 92, 93, 99, 109. 
Cathartics cholagogue, lower 

blood pressure, 279. 
Cervical cord, injury to, pro- 
duces bradycardia, 98. 
Chloral, hydrate of, 282. 
Chloralamid, 284. 
Chloralose, 285. 
Chloroform, 282. 
Circulation, condition of, up to 

middle life, 11. 
Colchicum, use of, in senile 

heart, 278. 
Cornaro, Luigi, 253. 

his diet, 254. 
Cullen's definition of gout, 163. 

Death, rarely due to age alone, 1. 

defined, 9. 

sudden, from emotion, 31. 

from angina, 138, 139. 

from age, typical, 18. 
Decay, premature, 5. 

final stage of development, 4. 
Delirium cordis, 113. 

prognosis in, 290. 
Deposits of urates in gouty 

joints, 164. 
Depressor nerve of heart, 38. 
Development ends only with 
death, 4. 

may be precocious, 4. 



Developmental phenomena may 
be terminal as well as In- 
itial, 4. 
Diathesis, gouty, 161. 
Diet, dry, 252. 

Cornaro's, 254. 
Dietaries, 237. 
Dietetic regulations, 238. 
Digitalis, use of, 260. 
accumulation of, 259. 
accumulation, how to avoid, 

object and mode of using, 263. 
must be combined with vas- 
cular stimulants, 266. 
Dilatation of heart,time required 
to produce, 44. 
effect of, in displacing apex- 
beat, 53. 

Emotion, intensity of, an im- 
portant factor, 45. 
may prove suddenly fatal, 31. 
fruitful source of heart 
trouble, 31. 
Epilepsy, character of attack in 

bradycardia, 104. 
Excess in food more dangerous 

than in drink, 236. 
Exercise, 232. 

Exertion, effect of, on an an- 
aemic pulse, 47. 
danger of unduly prolonged, 
to the heart, 30. 

Pakeers, Indian, how they slow 

the heart, 68. 
Fasting men, 253. 
Flatulence, disturbs the heart 

directly, 280. 
disturbs the heart reflexly, 

Force, vital, what it is, 9. 

cause of failure of genesis, 10. 
Fothergill's case of voluntary 

slowing of heart, 67. 

Fermentation test not devoid of 

fallacy, 190. 
Fluids must be restricted at 

meal times, 243. 
less injurious between meals, 


Giants,what they are, 12 (note). 
Graves' disease, syndrome of, 71. 
Glycosuria, gouty, 191. 

cause of, 195. 
Glycuronic acid decomposes cop- 
per in Fehling's test, 190. 
Gout, Gullen's definition of, 163. 
in no respect inflammatory, 

resolution of paroxysm al- 
ways Incomplete, 164. 
temperature of affected joint, 

Balfour, W., his treatment 

of, 172. 
Sir W. Temple's treatment 

of, 170. 
The Rhyngrave's treatment 

of, 171. 
massage in the treatment of, 
Gouty diathesis, what it is, 161. 

present in every one, 162. 
Gouty paroxysm a mere episode 
in its history, 163. 
history of a, 165. 
due to infarction, 166. 
Growth, influence of heredity in 
causing cessation of, 13 
(note) . 
precocious, not identical with 
premature development, 5 
(note) . 
conditions of, in early life, 11. 

Haemogenesis, interference with, 

Haemolysis, causes of, 226. 
Heart always hypertrophied in 

the old, 22. 



Heart, changes in, from age, 22. 

sources of vigour in the 
senile, 25. 

cause of trouble in the senile, 

changes in, when dilated, 52. 

idiopathic enlargement of, 89. 

gouty heart, 34. 

nervous, 34. 

innervation of, 37. 

inhibition of, 43. 

inhibition of, favours dilata- 
tion, 43. 

proportion of senile, to or- 
dinary heart affections, 

proportion of anginas among 
senile hearts, 144. 

proportion of anginas among 
males and females, 144. 

proportion of anginas cured, 

essential lesion of the senile, 

symptoms of the senile, 35. 

troubles of the, always alarm- 
ing, 214. 

troubles rarely arise from 
failure of the trophic 
nerves, 215. 

troubles may be remedied at 
any age, 216. 

fatty, diagnosis of, 249. 

supposed fatty, generally only 
weak, 250. 

irritable, 217. 

affections often last long, 219. 
Hemi-systolic bradycardia, 92. 
Hyalin fibroid disease, 200. 
Hyperdicrotism in tachycardia 
indicates danger, 79. 

Infarction, what it is, 166. 

cause of gouty paroxysm, 166. 
Inhibition of heart, 43. 

favours dilatation, 43. 

Interference, vagus, the cause of 

irregularity, 48. 
Irregular cardiac action, case 
of, 46. 
causes of, 48. 
diminishes efficacy of heart 

beat, 41. 
danger of, 40. 
is never unimportant, 41. 
prognosis in, 287. 
Ischsemia, cardiac, its relation to 
angina, 126. 
causes of, 126. 
cause of pain in angina, 131. 

Jenner, Edward, first to point 
out that ischsemia was the 
cause of pain in angina, 

Katabolic nerve, the, of the 

heart, 38. 
Kidney, relations of, to heart, 
Bright's idea of, 197. 
Traube's idea of, 197. 
George Johnson's idea of, 198. 
GuU and Sutton's idea of, 200. 
the red, contracting, 196. 
the senile, 202. 
the senile, a true gouty, 202. 
the gouty, preventable, 202. 
Knobs, Heberden's, 178. 
Kreatin, and kreatinic acid, de- 
compose copper in Feh- 
ling's solution, 190. 

Life defined, 8. 

form of energy, 7. 
"Luxus" heart, the, 34. 

not due to overfeeding alone, 

treatment of gouty 
paroxysm by, 170. 
Metabolism, danger of imper- 
fect, 223. 



Morphia, uses of, 281. 
Muscles, twittering of the, 183. 
Myocardium, weakness of the, 
its symptoms, 33. 
failure of the, 220. 
failure of the, treatment of, 

NaUs, ridged, 177. 

furrowed, 177. 
Narcotics, danger of, to the 
senile heart, 257. 

use of, 281. 
Nitrite of sodium, 275. 
Nitrites, action of, 275. 
Nitro-glycerlne, 277. 
Nodosities, Haygarth's, 180. 
Nux vomica as a heart tonic, 268. 

Obesity, how to reduce, 248. 
Overwork, effect of, on heart, 30. 

Pain, cause of, in gout, 168. 
Palpation of heart, 52. 
Palpitation, 63. 

prognosis of, 289. 
Paraldehyde as a hypnotic, 284. 
Percussion of heart, 52. 
Plethora, 30. 
Poisons, various, slow the heart, 

Precordial anxiety, 35. 

prognosis of, 287. 
Precordial pains not always 
anginous, 116. 

many varieties of, 117. 
Prognosis in heart affections, 

Puberty, cause of (note), 12. 
Pulse and blood require atten- 
tion, 224. 

during tremor cordis, 65. 

in tachycardia, 69. 

in Graves' diseases, 71. 

in palpitation, 63. 

normal, sometimes unusually 
slow, 96. 

Raynaud's disease (note), 85. 

Regurgitation, aortic, how 
brought about, 57. 
ventricular, Krehl's account 
of it, 60. " 

Remora of serous plasma in 
inter-vascular spaces, 27. 

Rest, importance of, in treat- 
ment of senile heart, 

Rhyngrave, the, his cure for 
gout, 171. 

Sclerosis, coronary, its relation 

to angina, 125. 
Scott, Sir W., on tremor cordis, 

Senile degeneration of the heart 

from the morbid anato- 
mist's point of view, 32. 
Soda as antacid, 278. 
Sound, booming first, what it 

signifies, 54. 
a booming second, what it 

signifies, 57. 
Sounds of heart, progressive 

alteration of, as dilatation 

proceeds, 54. 
Spa treatment, danger of, in 

senUe heart, 251. 
Spinal accessory, compression of, 

slows heart, 102. 
Sphygmogram of hemi-systolic 

bradycardia, 106. 
of true bradycardia, 107. 
of feeble and irregular pulse, 

of irregular pulses in dilated 

hearts, 47. 
of pulse of tachycardia, 78. 
Stimulant, hot water the best 

cardiac, 244. 
Stimulants, vascular, their use, 

drugs that are, 275. 
Strophanthus, use of, 267. 



Strychnine as a heart tonic, 268. 
Sympathetic, the katabolic 

nerve of the heart, 38. 
Symptoms, objective, of senile 

heart most reliable, 224. 
Syndrome of Graves' diseases, 71. 
of tachycardia, 71. 
of true angina, 124. 
Systole shortened in tachycardia, 


Tachycardia, or heart hurry, 
prognosis of, 289. 
treatment of, 292. 
physiological, 70. 
pathological, 72. 
from poisoning, 75. 
reflex, 82. 
action of augmentor nerve 

in, 83. 
often accompanies mitral 

stenosis, 74. 
sometimes emotional, 85. 
two cases of, 85. 
Tea, tobacco, etc., as causes of 

angina, 127. 
Temperance in all things im- 
portant preservative of 
cardiac health, 236. 
Temple, Sir W., on the treats 

ment of gout, 170. 
Tissues condense with age, 16. 
Tithonus a typical aged man, 16. 

dies in real life, 17. 
Thrombosis of veins common in 
gout, 167. 

Thrombosis, source of many 

accidents in gout, 173. 
Tobacco, use of, 254. 

dangerous In senile heart, 255. 
Townsend, case of Colonel, 67. 
Tremor cordis, 64. 

often arises from flatulence, 

is never emotional, 68. 
prognosis in, 289. 
sudden onset of, 65. 
treatment of, 292. 
Treatment of myocardiac fail- 
ure, 231. 
of various cardiac symptoms, 
Turgescence, red, in gout, its 
cause, 168. 

Uric acid decomposes copper of 
Fehling's test, 190. 

Vagus, the anabolic nerve of the 
heart, 39. 
compression of, produces 
tachycardia, 90. 

Vascular stimulants, action of, 
must be combined with car- 
diac tonics in treating 
senile heart, 266. 

Venoslty of blood, cause of, 160. 

Vichy water as an antacid, 278. 

Water, hot, sipping, the best 
stimulant for the heart,